Inspection visit
Inspection
14 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0567
Honor the resident's right to manage his or her financial affairs.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, and interview, the facility failed to obtain written authorization to
manage resident's personal funds, and failed to deposit resident's, whose care is funded by Medicaid,
personal funds over $50.00 in an interest bearing account. This failure affects six residents (R3, R6, R15,
R19, R31, and R233) out of six reviewed for personal funds management on the sample list of 23.
Residents Affected - Some
Findings include:
On 4/20/22 at 3:55 pm, V1, Administrator, stated, We don't really have a resident trust fund, with the
exception of one of our residents, (R6), who has a trust account managed by the fiscal department from the
hospital side of the building. (R6) is a Medicaid recipient and is under a state guardianship. V1 continued,
What we do have is money we keep locked in the safe inside the medication room for residents who want to
be able to use cash for something while they are here. V1 further stated, We are not the representative
payee for any resident. The families do bring in money for some of our residents and we accept those funds
for them, and we do provide that money to residents when they request cash.
1) On 4/20/22 at 3:59 pm, the facility's Personal Cash Box Inventory (individual accounting sheets)
documents R3 had a balance of cash in the amount of $16.94, R6 had a cash balance of 45 cents, R15
had a cash balance of $26.00, R19 had a cash balance of $286.40, R31 had a cash balance of $80.00 on
11/19/21, and R233 had a cash balance of $65.00. Each of these Cash Inventory Sheets documented a
variety of deposits and withdrawals for each resident recorded by a variety of facility personnel.
On 4/20/22 at 4:04 pm, V1, Administrator, with witness V8, Licensed Practical Nurse, made a physical
accounting of these resident's personal funds.
On 4/21/22 at 10:23 am, V1, Administrator, stated, We do not have written authorizations to manage the
resident's personal funds. A written authorization is not part of the admissions contract. V1 further stated,
We are not managing the resident's funds, we are just holding their funds for safekeeping in case a resident
wants to spend something on their own. V1 did affirm the facility does safeguard, accept deposits, disperse
withdrawals, and was acting as a fiduciary for, these resident's personal funds.
2) R31's Personal Cash Box Inventory documented R31 received a deposit of $80.00, and subsequently
withdrew this same $80.00, on 11/19/21. R31's Census Detail dated 4/21/22 documents R31's care in the
facility is funded by Medicaid.
On 4/21/22 at 10:23 am, V1, Administrator, stated, (R31) has a Medicaid Payer source. (R31) has 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 13
Event ID:
146049
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0567
zero balance, but those funds ($80.00) were not placed in an interest bearing account.
Level of Harm - Minimal harm
or potential for actual harm
3) R19's Personal Cash Box Inventory documented R19 had maintained a cash balance consistently in
amounts between $102.00 and $311.00 since 9/4/20, with a current balance (4/20/22) of $286.40. R31's
Census Detail dated 4/21/22 documents R19's care in the facility is funded by Medicaid.
Residents Affected - Some
On 4/20/22 at 3:55 pm, V1, Administrator, stated, (R19) is a Medicaid recipient. What is it then, anything
over $100.00 should be in an interest bearing account?
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 2 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0568
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing
home.
Based on observation, record review, and interview, the facility failed to provide quarterly statements to
residents or their representatives to account for resident's personal funds entrusted to the facility on the
resident's behalf. This failure affects six residents (R3, R6, R15, R19, R31, and R233) out of six reviewed
for personal funds on the sample list of 23.
Findings include:
On 4/20/22 at 3:55 pm, V1, Administrator, stated, We don't really have a resident trust fund, with the
exception of one of our residents, (R6), who has a trust account managed by the fiscal department from the
hospital side of the building. (R6) is a Medicaid recipient and is under a state guardianship. V1 continued, I
receive statements for (R6's) Trust Account. V1 further stated, The facility is not a representative payee for
any resident.
On 4/20/22 at 3:59 pm, the facility's Personal Cash Box Inventory (individual accounting sheets) documents
R3 had a balance of cash in the amount of $16.94, R6 had a cash balance of 45 cents, R15 had a cash
balance of $26.00, R19 had a cash balance of $286.40, R31 had a current zero balance, however, did have
a cash balance of $80.00 on 11/19/21, and R233 had a cash balance of $65.00. Each of these Cash
Inventory Sheets documented a variety of deposits and withdrawals for each resident recorded by a variety
of facility personnel.
On 4/20/22 at 4:04 pm, V1, Administrator, and witness V8, Licensed Practical Nurse, made a physical
accounting of these resident's personal funds.
On 4/21/22 at 10:23 am, V1, Administrator, stated, I have not sent out any quarterly statements for these
resident's funds. I am sure (V10), Fiscal Manager, sends statements to the State Guardian for (R6).
The (facility) Resident Trust Account Bank Statement dated 3/31/22 documents a current balance of
$2,857.91.
On 4/21/22 at 10:55 am, V10, Fiscal Manager, confirmed by stating, (R6) is the only resident who has
money in this trust account. At 11:20 am, V10 stated, I have not sent any quarterly statements to (R6's)
State Guardian. If someone was to give me that information, I could start doing that.
On 4/22/22 at 9:38 am, R19 stated, I know if I put any money in with what they keep for me, they write it
down on the sheet and give me a receipt like a little ticket, but they don't ever give me a statement like a
bank would send. R19's Personal Cash Box Inventory (sheet) documents the most recent transaction from
R19's cash balance was 1/28/21.
On 4/22/22 at 10:15 am, V12, Power of Attorney for R15, stated, As far as I know (R15) doesn't have any
money at the facility. The statements I receive are when the bill comes, they have never sent me anything
like a bank statement showing (R15) has a cash balance.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 3 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0570
Assure the security of all personal funds of residents deposited with the facility.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review and interview, the facility failed to maintain a surety bond, or other
financial security, in an amount sufficient to protect all resident funds deposited with the facility. This failure
affects six residents (R3, R6, R15, R19, R31, and R233) out of six reviewed for personal funds on the
sample list of 23.
Residents Affected - Some
Findings include:
On 4/20/22 at 3:55 pm, V1, Administrator, stated, We don't really have a resident trust fund, with the
exception of one of our residents, (R6), who has a trust account managed by the fiscal department from the
hospital side of the building. V1 further stated, We do have some resident's money locked in our safe in the
medication room for safekeeping for when a resident wants to spend something for themselves.
On 4/20/22 at 3:59 pm, the facility's Personal Cash Box Inventory (individual accounting sheets) documents
R3 had a balance of cash in the amount of $16.94, R6 had a cash balance of 45 cents, R15 had a cash
balance of $26.00, R19 had a cash balance of $286.40, R31 had a current zero balance, however, did have
a cash balance of $80.00 on 11/19/21, and R233 had a cash balance of $65.00. Each of these Cash
Inventory Sheets documented a variety of deposits and withdrawals for each resident recorded by a variety
of facility personnel. (These resident personal cash balances, including R31's $80.00, equal $474.79.)
On 4/20/22 at 4:04 pm, V1, Administrator, and witness V8, Licensed Practical Nurse, made a physical
accounting of these resident's personal funds.
The (facility) Resident Trust Account Bank Statement dated 3/31/22 documents a current balance of
$2,857.91.
On 4/21/22 at 10:55 am, V10, Fiscal Manager, confirmed by stating, (R6) is the only resident who has
money in this trust account.
The total of the resident cash balances plus the resident trust account equal $3,332.70.
The facility's Resident Fund Bond, number ****1109, dated as in effect 11/14/21 through 11/14/22,
documents a bond amount of $2,000.00, insufficient to secure the total resident personal funds entrusted to
the facility.
On 4/21/22 at 1:55 pm, V1, Administrator, stated, I saw that bond. I am in communication right now to get
the bond increased to $3,000.00. V1 then stated, I guess it really needs to be increased to $5,000.00.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 4 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to obtain and document Physician Orders for resident advance
directives. This failure has the potential to affect one of three residents (R83) reviewed for advanced
directives in the sample of 23.
Finding include:
R83's Current Physician's Orders (POS) do not document an order for Do Not Resuscitate (DNR) or
Cardiopulmonary Resuscitation (CPR). R83's electronic medical record does not include an Illinois
Department of Public Health (IDPH) Uniform Practioner Order for Life-Sustaining Treatment (POLST) Form.
This form is used to document a resident's preference for life sustaining treatment. R83 has not completed
this form since being admitted to the facility.
The facility's policy with the revision date of 3/2020 titled Advance Directives and Psychiatric Advance
Directives states section labeled POLICY: It is our policy to comply with these laws by honoring the
treatment preferences expressed by our patients in their Advance Directives. Staff (inpatient and outpatient)
will honor those preferences supported by a physician order which is written during the stay or visit. Staff
also have the authority to honor a do not resuscitate order presented on the IL Department of Public Health
form titled Uniform Do Not Resuscitate (DNR) Advance Directive, when presented during the patient stay or
visit. This document must become a permanent part of the patient's medical record.
On [DATE] at 11:30 am V1, Administrator and V2 , Director of Nurses both stated Yes the resident should
have a physician's order and or POLST form completed upon admission because the form is in our
admission packet.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 5 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interview, the facility failed to provide required Advanced Beneficiary Notices to
residents having their Medicare Part A services terminated, precluding residents from selecting the options
to continue these services by billing Medicare for an appeal, or at their own expense. This failure affects two
residents (R6 and R29) out of three reviewed for Beneficiary Protection Notification on the sample list of 23.
Residents Affected - Few
Findings include:
1) R6's Census Detail dated 4/21/22 documents R6 began to receive services under Medicare Part A
benefits on 1/6/22, and subsequently had Medicare Part A services terminated on 1/17/22. This same
Census Detail documents R6 remained in the facility after the termination of Part A services and was a
current resident at the time of the survey.
R6's Beneficiary Protection Notification Review Form, undated, completed by the facility's Social Services
Designee, V9, documents R6's Medicare Part A services were terminated by the facility 1/17/22, and R6
was not issued an Advance Beneficiary Notice (ABN) because (R6) was At prior level, no request for added
services, no skilled nursing, no therapy.
On 4/21/22 at 9:14 am, V1, Administrator, stated, We did not give an ABN to (R6), I looked at the rules and
I thought we did not have to give the ABN unless the resident made a request for continued services.
2) R29's Census Detail dated 4/21/22 documents R29 was admitted to the facility 3/16/22, began to receive
Medicare Part A services upon admission, and R29's Medicare Part A benefits were subsequently
terminated 4/9/22. This same Census Detail documents R29 remained in the facility after the termination of
Medicare Part A benefits and was a current resident at the time of the survey.
R29's Beneficiary Protection Notification Review, undated, completed by V9, Social Services Designee,
documents R29 did not receive an Advance Beneficiary Notice because, New in my position, did not
complete ABN.
On 4/21/22 at 9:14 am, V1 confirmed the ABN notice was not provided to R29, stating, We are all new in
our positions, we are all trying to pick up pieces and learn the processes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 6 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
Based on record review and interview the facility failed to provide resident (R14) a facility Bed Hold Policy
when being discharged to the hospital. R14 is one of one resident reviewed for Bed Hold Notices in the
sample of 23.
Findings include:
R14's Diagnosis Sheet dated 4/22/22 includes the following diagnosis: Atherosclerotic Heart Disease of
Native Coronary Artery without Angina Pectoris and Acute Respiratory Failure with Hypoxia.
R14's progress note dated 4/8/22 documents R14 was sent to emergency room for shortness of breath and
chest tightness oxygen saturation was 48% DuoNeb given oxygen applied at 4 liters nasal cannula was
able to get oxygen saturation to 59%.
The Census for R14 shows R14 was transferred to the hospital on 4/8/22.
R14's electronic medical record does not have any bed hold form available documenting R14 was
transferred to the hospital and offered bed hold.
The facility's policy titled Discharge or Transfer of Resident dated November 2003 documents.
Section F : Hold Bed/readmission:
1. Hold bed
a) Family or Resident will notify staff that bed is to be held.
b) Family will sign Hold Bed Form. If family is not present and resident is alert and responsible, the form will
be taken to the Resident for signature.
c) Hold Bed Form will be signed in the Resident Home and a copy forwarded to the Business Office.
d) If family unavailable, a telephone order can be taken to hold bed.
V1, Administrator and V2 Director of Nurses stated on 4/22/22 at 11:30 am The bed hold policy and the
notice of transfer is in the admission packet. The nurse that discharged R14 should of completed the forms.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 7 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to encode, format, and transmit a resident's Minimum Data
Set for discharge from the facility. This failure affects one resident (R1) out of 12 reviewed for Minimum Data
Sets on the sample list of 23.
Residents Affected - Few
Findings include:
R1's Nurse's Progress Note dated 11/8/21 document a care plan meeting with the resident's (2 family
members, V13 and V14), the facility's Therapy Staff (un-named), Assistant Director of Nursing, Registered
Dietician, Social Services Designee, and Activity Director, to arrange home services for R1's pending
discharge from the facility.
R1's Nurse's Progress Note dated 11/10/21 documents nursing staff arranged a post-discharge follow-up
appointment for R1.
R1's Nurse's Progress Note dated 11/11/21 documents R1 was discharged from the facility and left the
building accompanied by V14, Family Member.
R1's Census Detail documents and confirms R1 was discharged from the facility 11/11/21.
R1's Minimum Data Set List dated 4/20/22 documents there was not a discharge Minimum Data Set (MDS)
initiated, encoded, formatted, nor transmitted for R1's discharge from the facility on 1/11/21.
On 4/21/22 at 10:55 am, V3, Assistant Director of Nursing, stated, Our current MDS person works as a
consultant. I am in a certification class right now.
On 4/21/21, V3 Assistant Director of Nursing, stated, and V1 Administrator, and V2 Director of Nursing,
agreed and confirmed, A discharge MDS should have been completed for R1's discharge on [DATE], and
the MDS was not completed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 8 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to develop and implement a resident's comprehensive care
plan, documenting resident needs and services required to meet those needs. This failure affects one
resident (R29) out of 12 reviewed for care plans on the sample list of 23.
Findings include:
R29's Census Detail dated 4/21/22 documents R29 was admitted to the facility on [DATE] under Medicare
Part A services. This same Census Detail documents R29 had changed payer source to Medicaid on 4/9/22
and remained in the facility as a resident.
R29's Minimum Data Set (MDS) list documents R29 entered (entry MDS) the facility 3/16/22. This same
MDS List documents a comprehensive resident assessment completed on 3/22/22.
R29's Care Plan dated 4/20/22 documents one Focus area for: The resident has a nutritional problem or
potential nutritional problem r/t (related to) potential decrease in intake due to environment change.
R29's Medical Diagnoses List includes Iron Deficiency Anemia, Urinary Tract Infection, Alzheimer's
Disease, Syncope and Collapse, Muscle Weakness, Difficulty Walking, Acute on Chronic Heart Failure,
Ulcerative Colitis, Anxiety Disorder, Diverticulosis, Gout, Gastro-Esophageal Reflux Disease, and
Osteoarthritis.
On 4/21/22 at 10:55 am, V1, Administrator, stated, and V2 Director of Nursing, and V3 Assistant Director of
Nursing, agreed, We have had a lot of staff changes and while I know all of us weren't here during that time
period, we own it, it (R29's care plan) wasn't done.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 9 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, interview and observation, the facility failed to monitor a resident's (R20) pressure
ulcer and failed to complete a proper dressing change of R20's pressure ulcer. R20 is one of one resident
reviewed for pressure ulcers in the sample of 23.
Residents Affected - Few
Findings include:
R20's Diagnoses Sheet (current) includes the following diagnoses: Hospice, Congestive Heart Failure, End
Stage Renal Disease and Diabetes Mellitus.
R20's Physician Order Sheet (POS) dated April 2022 documents the following order: Cleanse Wound with
Normal Saline and pat dry, Apply Misoprostol 0.0024% / Lidocaine 2% / Phenytoin 5% Cream topically to
affected area daily and cover with primapore dressing.
R20's Care Plan (current) documents the following: (R20) has Potential for Skin Breakdown: Stage 2 (Right)
Buttock, Weekly Treatment documentation to include measurement of each area of skin breakdown's width,
length, depth, type of tissue and exudate with any other notable changes and observations.
Skin/Wound Assessments for R20 are documented as follows:
2/12/22 - Coccyx - Superficial loss of skin, Pink Bed (no measurements or stage is documented).
3/3/22 - Pink Area on Buttock - 0.5 centimeters by 0.5 centimeters (cm) (documentation does not discern
what buttock or stage)
3/10/22 - Coccyx - Sheared area (no measurements or stage is documented).
3/21/22 (11 days later)- Right Buttock - 0.8 cm by 0.8 cm x 0.1 cm (no stage is documented).
3/28/22 - Right Buttock - 0.8 cm by 0.8 cm by 0.1 cm, Stage two.
4/8/22 - Right Buttock - No description or measurements
4/15/22 - Right Buttock - No description or measurements
4/18/22 - (21 days later) - Right Buttock - 1.0 cm by 1.0 cm by 0.1 cm, Stage two (worsened since 3/28/22)
On 4/21/22 at 2:10 pm V2, Director of Nursing Confirmed that the area listed in the above measurements
as coccyx was actually R20's right buttock, not the coccyx. V2 also confirmed that R20's pressure ulcer
should have been measured weekly.
On 4/21/22 at 3:15 pm, V2 and V11 Licensed Practical Nurse positioned R20 in the bathroom standing over
the sink. V11 washed V11's hands and applied a clean pair of gloves. R20's buttocks were exposed and a
dressing (undated) was removed from the upper right buttock by V11, revealing a stage two pressure ulcer.
V11 also identified two new open areas below the upper right buttock pressure wound. Using the same
gloves, V11 then cleansed the original upper open wound and the two new identified
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 10 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
open areas with wound cleaner. V11 did not wash V11's hands, nor did V11 change V11's gloves after
cleaning the three open wounds. V11 then measured all three open wounds by placing a clear plastic graph
sheet over all three open areas, drawing an outline of each wound on the graph sheet. V11 did not wash
V11's hands or change V11's gloves at this time either. V11 then proceeded to apply the Misoprostol
0.0024% / Lidocaine 2% / Phenytoin 5% Cream to the right upper open wound with V11's contaminated
gloved fingers, contaminating the upper pressure wound. V11 then picked up the primapore dressing with
V11's contaminated gloves and placed the contaminated dressing on R20's upper wound. At this time R20
verbalized R20 was getting tired and needed to sit down. R20 was assisted down into R20's wheelchair by
V11, contaminating the uncovered two new open areas. V2 left the room to retrieve additional supplies for
the two new identified areas and returned with the supplies. V11 washed V11's hands and applied clean
gloves. V11 then stood R20 back up contaminating V11's gloves. V11 did not change V11's gloves nor did
V11 re-clean R20's contaminated wounds after they had come in contact with the contaminated wheelchair
seat bottom. V11, using contaminated gloves, applied the Misoprostol 0.0024% / Lidocaine 2% / Phenytoin
5% Cream with V11's fingers and then covered both new open wound areas with the primapore dressing,
again contaminating the wounds with dirty gloves.
On 4/21/22 at 3:15 pm, the above open wounds measured as follows:
#1 Right Upper Buttock Stage 2 - 1.3 cm by 1.3 cm by 0.1 cm (worsened since 4/18/22)
#2 Right Upper Buttock (middle) Stage 2 - 0.8 cm by 0.5 cm by 0.1 cm (new area)
#3 Right Upper Buttock (distal) Stage 2 - 1.1 cm by 2.0 cm by 0.1 cm (new area)
On 4/21/22 at 3:35 pm, V11 confirmed V11 had not used proper hand hygiene and glove usage during
R20's wound care. V11 stated I change (R20's) dressing every day and the two new identified areas were
not there yesterday (4/20/22). (R20) does not sleep in the bed, (R20) sleeps upright in the recliner and
therefore doesn't get pressure off (R20's) bottom.
On 4/21/22 at 3:40 pm, V2 confirmed R20's wound care was incomplete by V11 not using proper hand
hygiene and glove usage. V2 also confirmed that R20 sleeps upright in a recliner.
On 4/21/22 at 3:50 pm, R20 stated I know I need to get off my bottom, but I just don't like sleeping in the
bed maybe I'll try again.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 11 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based on observation, record review, and interview, the facility failed to post the required nurse staffing
data on a daily basis and failed to maintain the required nurse staffing data for 18 months. This failure has
the potential to affect all 32 residents residing in the facility.
Residents Affected - Many
Findings include:
On 4/19/22 at 2:45 pm, there was not a daily nurse staffing posting anywhere in the facility.
On 4/19/22 V1, Administrator, stated, I am going to be honest with you, we are not real good about getting
the posting up there, but this is the plastic holder where it should be. V1 pointed to a plastic holder on the
wall next to a large bulletin board and stated, Today it is empty.
On 4/22/22 at 12:35 pm, the daily nurse staffing posting was dated from 4/21/22.
On 4/22/22 at 12:35 pm, V1, Administrator, stated, My ADON (Assistant Director of Nursing) called in sick
today so I am looking for the blank posting sheets on her desk. I don't know if we have kept 18 months of
those postings because I have only worked here since January. I know there is about 4 boxes of all kinds of
paperwork but I don't know if those are in there.
On 4/22/22 at 3:30 pm, V1 did not provide the 18 months of required maintained daily nurse staffing
documentation.
The facility's Centers for Medicare and Medicare Services Form 802 dated 4/19/22 documents 32 residents
reside in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 12 of 13
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
146049
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Iroquois Resident Home, The
200 Fairman Avenue
Watseka, IL 60970
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, record review, and interview, the facility failed to maintain kitchen equipment to
prevent the potential for cross contamination of food. This failure has the potential to affect all 32 residents
residing in the facility, all of whom consume food prepared in the facility kitchen.
Findings include:
On 4/19/22 at 10:51 am, the facility's cooking range vent hood had more than fifteen dark brown greasy
streaks with grease trails down the metal slats of the vent hood. These greasy streaks each terminated on
the bottom edge of the vent hood with hanging drops and drips of the dark brown grease. The vent hood,
and hanging grease drops, were directly over the cooking surfaces, burners, and grill surface of the cooking
range. The vent hood and hanging grease drops were also directly over heating and warming ovens.
On 4/19/22 at 10:51 am, V4, Kitchen Coordinator/ Manager, touched a fingertip to one of the hanging
grease drops and rubbed the dark brown greasy material between two fingers and stated, I have never
noticed that.
The range vent hood had a sticker placed on the outside edge which documented, Last clean date 8/2021,
cleaning next due 3/2022. V4 stated, The cleaning guy did not come in March so I expect he should be due
any time now.
The facility's Centers for Medicare and Medicaid Services Form 802 Matrix, dated 4/19/22, documents 32
residents reside in the facility, all of whom consume food prepared by cooking in the kitchen, including
items prepared on the range, grill, and warming ovens.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146049
If continuation sheet
Page 13 of 13
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
14 citations 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.
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
F568 - Accounting and Records
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
F570 - Assurance of financial security
Assure the security of all personal funds of residents deposited with the facility.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
FAQ · About this visit
Common questions about this visit
What happened during the April 22, 2022 survey of IROQUOIS RESIDENT HOME, THE?
This was a inspection survey of IROQUOIS RESIDENT HOME, THE on April 22, 2022. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at IROQUOIS RESIDENT HOME, THE on April 22, 2022?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to manage his or her financial affairs."
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.