Autumn Meadows Of Cahokia

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

intact and required partial assistance with transfer.Resident R3's Care Plan does not address risk of sexual abuse.On 10/10/25 at 1:43 PM, Resident R3 stated shortly after she was admitted here, she was at the nurse's station when Resident R1 grabbed her sweater and offered her ten dollars for a bl** jo*. On 10/10/25 at 2:50 PM, Resident R3 stated she told staff who were working at the time of this allegation but does not recall their names.On 10/10/25 at 3:15 PM, V1 (Administrator) stated the Facility did not have any abuse investigations for Resident R1 and Resident R3. On 10/14/25 at 4:00 PM, V1 stated she does not understand how the incident between Resident R1 and Resident R3 could be considered sexual abuse, because there was no physical touching. Resident R1 was just asking Resident R3 if she would be interested and does not feel that would be upsetting to people.On 10/14/25 at 1:47 PM, V1 stated

she expects staff to follow its abuse policy.The Facility's Abuse Prevention Program Policy revised 2/20/25 documents the Facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical). Abuse is defined as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Bottom of Form

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Meadows of Cahokia

2 Annable Court Cahokia, IL 62206

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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

asked what the Facility was doing about it. Resident R1 was interviewed about the incident and replied, What is wrong with that?3.) Resident R3's Face Sheet documents Resident R3 was admitted to the facility on [DATE REDACTED] with diagnoses including diabetes mellitus type two and muscle weakness.Resident R3's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R3 was cognitively intact and required partial assistance with transfer.Resident R3's Care Plan does not address risk of sexual abuse.On 10/10/25 at 1:43 PM, Resident R3 stated shortly after she was admitted here, she was at the nurse's station when Resident R1 grabbed her sweater and offered her ten dollars for a bl** jo*. On 10/10/25 at 2:50 PM, Resident R3 stated she told staff who were working at the time of this allegation but does not recall their names.On 10/10/25 at 3:15 PM, V1 (Administrator) stated the Facility did not have any abuse investigations for Resident R1 and Resident R3. V1 was notified that Resident R3 alleged Resident R1 grabbed her sweater and offered her money for sexual favors shortly after her admission to the Facility.On 10/14/25 at 10:25 AM, V1 stated she did not report the allegation made by Resident R3 about Resident R1 that was reported to her on 10/10/25. On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy.On 10/14/25 at 4:00 PM, V1 stated she does not understand how the incident between Resident R1 and Resident R3 could be considered sexual abuse, because there was no physical touching. Resident R1 was just asking Resident R3 if she would be interested and does not feel that would be upsetting.The Facility's Abuse Prevention Program Policy revised 2/20/25 documents the Facility affirms the right of our residents to be free from abuse (verbal, mental, sexual or physical). Abuse is defined as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Sexual abuse includes but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. documents Facility staff will report and investigate any allegations of abuse within timeframes required by Federal law. The Facility will initiate external reports to the Department within 24 hours upon receipt of an allegation or upon the formation of a reasonable suspicion of abuse. Bottom of Form

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Meadows of Cahokia

2 Annable Court Cahokia, IL 62206

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the Facility failed to report an allegation of abuse for 1 of 3 residents (Resident R3) reviewed for abuse in the sample of 6.Findings include:1.) Resident R3's Face Sheet documents Resident R3 was admitted to

the facility on [DATE REDACTED] with diagnoses including diabetes mellitus type two and muscle weakness.Resident R3's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R3 was cognitively intact and required partial assistance with transfer.Resident R3's Care Plan does not address risk of sexual abuse.On 10/10/25 at 1:43 PM, Resident R3 stated shortly after she was admitted to the facility, she was at the nurse's station and Resident R1 grabbed her sweater and offered her ten dollars for a bl** jo*. On 10/10/25 at 2:50 PM, Resident R3 stated she reported this incident to staff working at the time but could not remember their names.On 10/10/25 at 3:15 PM, V1 (Administrator) stated the facility did not have any abuse investigations for Resident R1 and Resident R3. V1 was notified that Resident R3 alleged Resident R1 grabbed her sweater and offered her money for sexual favors shortly after her admission to

the facility.On 10/14/25 at 10:25 AM, V1 stated she did not report the allegation made by Resident R3 regarding Resident R1.

On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy. On 10/14/25 at 4:00 PM, V1 stated she did not understand how the incident with Resident R1 and Resident R3 could be considered abuse since there was no physical touching. Resident R1 was just asking Resident R3 if she would be interested.The Facility's Abuse Prevention Program Policy revised 2/2023 documents abuse is defined as physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in the facility. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Facility staff will report any allegations of abuse within timeframes required by Federal law. The Facility will initiate external reports to the Department within 24 hours upon receipt of an allegation or upon the formation of a reasonable suspicion of abuse.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Meadows of Cahokia

2 Annable Court Cahokia, IL 62206

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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the Facility failed to thoroughly investigate abuse allegations from 1 of 3 residents (Resident R2) reviewed for abuse in the sample of 6.Findings include:1.) Resident R1's Face Sheet documents Resident R1 was admitted to the facility on [DATE REDACTED] with diagnoses including traumatic brain injury.Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documented Resident R1 was moderately cognitively impaired and ambulated by wheelchair.2.) Resident R2's Face Sheet documents Resident R1 was admitted to the facility on [DATE REDACTED] with diagnoses including intellectual disabilities.Resident R2's MDS dated [DATE REDACTED] documented Resident R1 was moderately cognitively impaired and ambulated by wheelchair.On 10/10/25 at 12:35 PM, Resident R2 stated, (Resident R1) touched me down there (pointed to genital area). The Facility's Initial Report sent to state surveying agency on 10/5/25 at 5:41 PM documents Resident R1 attempted to touch female resident Resident R2 on her private area at the nurse's station. The Facility's Investigation was provided on 10/10/25 at 12:36 PM. The investigation did not include any staff or resident interviews.On 10/10/25 at 1:37 PM, V1 (Administrator) provided an additional document that listed residents interviewed by V5 (Social Services Director)on 10/9/25. Residents listed included Resident R3, Resident R5, and Resident R6.On 10/10/25 at 1:43 PM, Resident R3 stated V5 just interviewed her about the incident between Resident R1 and Resident R2 earlier today.Resident R3's MDS dated [DATE REDACTED] documented Resident R3 was cognitively intact.On 10/10/25 at 3:10 PM, Resident R5 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility. Resident R5's MDS dated [DATE REDACTED] documented Resident R5 was cognitively intact.On 10/10/25 at 3:11 PM, Resident R6 stated she was not interviewed by V5 about inappropriate or unwanted touching in the Facility.Resident R6's MDS dated [DATE REDACTED] documented Resident R6 was cognitively intact.On 10/14/25 at 4:00 PM, V1 stated it is a problem if residents are saying they were not interviewed as part of the investigation.The Facility's Final Report documented V4 (Licensed Practical Nurse) reported the incident to V1 (Administrator).On 10/14/25 at 9:14 AM, V4 stated

she had no knowledge of Resident R2's allegation toward Resident R1 and did not report this to V1 because she knew nothing about it.On 10/14 25 at 12:52 PM, V1 stated the investigation she provided was complete.On 10/14/25 at 1:47 PM, V1 stated she expects staff to follow its abuse policy.The Facility's Abuse Prevention Program Policy revised 2/2023 documents Facility staff will investigate any allegations of abuse within timeframes required by Federal law.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet