Momence Meadows Nursing & Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was maintained in a clean, comfortable, and homelike manner and kept free of odors. This failure applies to 9 of 13 residents (R3, R5, R7, R8, R9, R10, R11, R12, and R13) reviewed for environment in a sample of 13 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective pest control services. This failure applies to 9 of 9 residents (R3, R5, R7, R8, R9, R10, R11, R12, R13) reviewed for pests in the facility.

Inspectors wroteBased on interview and record review, failed to ensure resident lice treatments and environmental cleaning stopped lice re-infection. This applies to 5 residents (R6, R10, R4, R2, R9) reviewed for infection control practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered within acceptable time parameters. This applies to 4 of 7 residents (R1, R11, R12, R13,) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect by failing to respond timely to call lights. This applies to 3 of 15 residents (R1, R6, R8) reviewed for call light response time in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's choice for a representative was honored. This applies to 1 of 16 residents (R3) reviewed for residents' rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who require assistance with care. This applies to 2 of 10 residents (R1, R6,) reviewed for ADLs.

Inspectors wroteBased on observation and interview, the facility failed to perform hand hygiene before and after providing incontinence care. This applies to 1 (R5) of 4 residents reviewed for infection control.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's rights to be free of sexual abuse. This applies to 2 of 2 residents (R3 and R4) reviewed for sexual abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident remained free from abuse. The facility also failed to keep a resident free from physical abuse, resulting in one resident striking another in the head with his cane and that resident requiring sutures. This applies to 1 out of 6 residents (R29) reviewed for neglect and abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a gastrostomy tube feeding received care and services to maintain his weight. This failure resulted in a resident experiencing significant weight loss of 13.49% in less than 39 days. This applies to 1 of 2 residents (R12) reviewed for gastrostomy tube use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have enough licensed nursing staff to pass medications in a timely manner and to consistently provide a resident's gastrostomy tube feeding as ordered. This applies to 15 residents (R1, R10, R12, R18-R29) reviewed for licensed nurse staffing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure significant medications were administered as ordered. This applies to 6 residents (R10, R12, R18, R19, R20, R28) reviewed for medications.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of staff to resident abuse and an allegation of resident-to-resident abuse to the Illinois Department of Public Health within the required timeframes. This applies to 3 of 3 residents (R1, R5, R9) reviewed for abuse reporting.

Inspectors wroteBased on interview and record review, the facility failed to investigate reported allegations of resident abuse, and subsequently failed to ensure residents were protected while the reported allegations were investigated. This applies to 3 of 3 residents (R1, R5, R9) reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe resident environment after a resident was able to obtain objects that could be used to threaten others. This applies to 2 residents (R1, R5) reviewed for safe environment.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record review, the facility failed to prevent resident to resident abuse. This applies to 2 of 5 residents (R2 and R3) reviewed for abuse in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident was free from abuse for one of three residents (R3) reviewed for abuse in a sample of 3. This failure resulted in R3 being physically slapped by a staff member which caused R3 to experience emotional distress and led to R3 displaying increased agitation, aggression, and combative behavior.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to refund resident funds after residents discharged from the facility. This applies to 3 of 3 residents (R1-R3) reviewed for resident funds.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide alternate food to meet residents need. This applies to 3 of 3 residents (R1, R6, and R15) reviewed for alternate food and nutritional adequacy in the sample of 15. R1's MDS (minimum data set) dated April 25, 2024, indicated R1 has a BIMS (brief interview of mental status) score of 15 and she is cognitively intact. On 5/21/24 at 9:30 AM, R1 stated during interviews that she is not getting the food alternatives because she did not order the item the previous day. R1 stated that during the lunch meal she did not get the item that was listed on the planned menu and she requested a vegetable salad. According to R1, the dietary staff refused to give R1 the vegetable salad that she wanted since the menu as planned was not served. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's POA (Power of Attorney) of the resident's change in condition. This applies to 1 of 3 residents (R1) reviewed for notification of changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who require ADL (Activities of Daily Living) assistance received grooming cares. This applies to 5 residents (R31, R33, R61, R36 & R230) reviewed for ADLs in the sample of 31. 1. On 12/19/23 at 1:57 PM, R61 was observed in the hallway in her wheelchair with the hair on the back of her head matted. R61's electronic health records showed that she is an [AGE] year old female with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, age-related osteoporosis, Alzheimer's disease, non-suicidal self-harm, and major depressive disorder. R61's care plan 1/9/23 showed, Self-Care Deficit with impaired Dressing and Grooming abilities . keeping nails short with no more than Extensive Assist time 1 Staff 6-7 days weekly . Special Note for ADL Care: may have fluctuations in . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post isolation signs for Personal Protective Equipment (PPE), and failed to follow infection control guidelines for pericare, hand hygiene, and wound care. This applies to 5 residents (R3, R7, R31, R59, R230) reviewed for infection control practices in a sample of 31.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications and obtain physician orders for residents' medication to be at the bedside. This applies to 2 residents (R31 & R68) reviewed for bedside medication in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the call lights accessible to dependent residents. This applies to 2 of 2 residents (R9 and R36) reviewed for accommodation of needs in a sample of 31.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a home-like environment for residents. This applies to one resident (R56) reviewed for homelike environment in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a resident-to-resident assault. This applies to two residents (R32 and R49) reviewed for abuse in a sample of 31.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure medications were completely flushed through a gastrostomy tube, and failed to ensure alcohol was dry before obtaining a blood glucose value. This applies to 2 residents (R3, R72) reviewed for quality of care in a sample of 31.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents' toenails were cut, and failed to protect the feet of a resident with circulatory problems. This applies to 2 of 10 residents (R36, R49) reviewed for foot care in a sample of 31.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure anti-contracture devices were applied as ordered. This applies to 1 resident (R72) reviewed for anti-contracture devices in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's room was free of trip hazards. This aplies to 1 of 31 residents (R69) reviewed for environmental risk in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary storage/containment of respiratory equipment when not in use, and failed to ensure that a resident could use their BiPAP (Bilevel Positive Airway Pressure) as ordered by the physician. This applies to 2 of 2 residents (R42 and R56) reviewed for use of respiratory equipment in a sample of 31.

Inspectors wroteBased on observation and record review, the facility failed to maintain temperature logs, label food items, and discard outdated food items. This applies to 2 residents (R10 & R6) reviewed for personal food storage in a sample of 31 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from neglect when a resident did not receive his psoriasis medication to prevent a psoriasis flare-up, and when the resident did not have weekly skin assessments to monitor his flare-up. These failures resulted in R1 experiencing a psoriasis flare-up, and then subsequently his skin lesions were not monitored. This applies to 1 of 7 residents reviewed for neglect in the the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's Cosentyx was available for administration. This failure resulted in a resident experiencing a psoriasis flare-up. This applies to 1 of 4 residents (R1) reviewed for medications in a sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to provide daily feeding tube site care. This applies to 2 of 3 residents (R2, R4) reviewed for feeding tubes in a sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent employee to resident mental abuse. This applies to 1 of 16 residents (R1) reviewed for abuse in a sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to immediately report an allegation of abuse to the Administrator or designee. This applies to 1 of 16 residents (R1) reviewed for abuse reporting in a sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff to carry out the functions of food service. This has the potential to affect all the residents who eat by mouth from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food on the menu was served as posted. This has the potential to affect all the residents who consume food from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check for safe food temperatures and failed to provide palatable foods. This applies to 83 residents who receive meals from the kitchen. Three residents do not eat food from the kitchen due to receiving nutrition via a gastrostomy tube.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a warm and clean environment. This applies to 8 residents (R241, R53, R46, R21, R240, R51, R32, and R66) reviewed for homelike environment in a sample of 25.

Inspectors wroteBased on observation and interview, the facility failed to ensure privacy for residents by leaving residents' urinary catheter drainage bags in view of passersby. This applies to 2 of 2 residents (R13 and R23) reviewed for catheter care in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Physician Orders for a pressure ulcer treatment and failed to follow clean technique during pressure ulcer dressing changes. This applies to 1 of 2 residents (R9) reviewed for pressure ulcers in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain orders for providing PICC (Peripherally Inserted Central Catheter) line care, and failed to change a PICC line dressing. This applies to 1 of 1 residents (R66) reviewed for intravenous access care in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage a resident's pain for a wound dressing change. This applies to 1 of 2 residents (R9) reviewed for pain management in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to document when a resident's narcotic pain medication was administered. This applies to 1 of 2 residents (R9) reviewed for pain medication administration in a sample of 25.