Health inspection·April 22, 2022

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 Page 1 of 13 146049 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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? 146049 Page 2 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 3 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 4 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 5 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 6 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 7 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 8 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 9 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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 146049 Page 10 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 11 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 12 of 13 146049 04/22/2022 Iroquois Resident Home, The 200 Fairman Avenue Watseka, IL 60970

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. 146049 Page 13 of 13