Inspection·May 4, 2023

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to ensure the facility was sufficiently staffed to meet the needs of the residents. This failure affects five residents (R5, R14, R20, R23, R28) on the sample list of 21. This failure has the potential to affect all 28 residents residing in the facility. Findings include: The facility's Resident Council Meeting Minutes documents the following nursing concerns: 4/19/22 residents would like more Certified Nursing Assistants (CNA's) on evening shift. On 5/19/22 residents would like more CNA's. 6/16/22 one resident stated was not getting their bath today because not enough staff. Residents say we are understaffed for CNA's on early evenings and weekends. 7/14/22 one resident stated sits too long when going to the bathroom around meal times and residents state would like more CNA's. 9/26/22 residents have concerns that there are not enough to help out in case of an emergency and complaints that CNA's like to stand around and visit when they hear call lights go off. 10/13/22 residents stated they need more CNA's. Resident stated they have had to wait on the toilet for 25-30 minutes several times before a CNA could come help. 11/13/22 residents stated they need more help on the weekend due to long call light wait times. 12/5/22 residents stated there are not enough CNA's. 2/6/23 residents raise concerns about the number of CNA's per shift. Residents stated lack of CNA's is affecting their care. 4/4/23 residents raised concerns about number of CNA's per shift. 5/2/23 a resident questioned staffing on weekends. On 5/2/23 at 9:39am, R28 stated R28 receives showers every three to four days. R28 stated, they are under staffed. On 5/2/23 at 2:45pm during the Resident Council Meeting with the State Surveyor, R20 stated the facility is short staffed CNA's on weekends. R20 stated R20 takes a diuretic which causes the need to use the bathroom frequently and R20 needs assistance to use the bathroom. R20 stated call light wait times are longer at night. During this same meeting, R5, R14, and R23 all agreed call light wait times were longer at night and on weekends. R5 stated R5 is not receiving showers twice a week due to not enough staff. R5's Electronic Medical Record (EMR) under Tasks-ADL (Activities of Daily Living) - Bathing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 2 of 4 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 05/04/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Prefers: Bath on Monday and Thursday Day shift documents R5 received a shower and/or bed bath on 4/8/23, 4/12/23, 4/19/23, and 5/3/23. R5's CNA Bathing Observation and Duties Sheet documents R5 received a shower and/or bed bath on 4/2/23 and 4/8/23. R5 did not receive a shower and/or bed bath twice a week during the weeks of 4/9/23, 4/16/23 and 4/23/23. There is no documentation is R5's EMR that R5 refused showers and/or bed baths during the weeks of 4/9/23, 4/16/23, or 4/23/23. Residents Affected - Many R28's EMR under Tasks-ADL-Prefers: Shower Wednesday and Saturday PM shift. This task sheet document R28 not available or not applicable. There is no documentation in R28's EMR or a CNA Bathing Observation and Duties Sheet in EMR noting refusal or R28 not available. On 5/4/23 10:48am, V1 Administrator stated the facility is working on hiring staff. V1 stated V1 and V2 determine staffing hours. On 5/4/23 11:45am, V2 Director of Nursing stated the facility has hired some night shift hires and have new hires going through the process. V2 stated it does not help when they do not show up and call off. V2 confirmed staff work 12 hour shifts. The Resident Census and Conditions of Residents report dated 5/2/23 document 28 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 3 of 4 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 05/04/2023 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 ensure the dishwashing machine was operating in a manner to sanitize residents food service dishes, wares, and utensils. This failure has the potential to affect all 28 residents residing in the facility. Findings include: On 5/3/23 at 9:06 am, V12, Dietary Aide, stated, The dishwasher is a high temp (temperature) machine, I check it every morning. V12 then placed a facility digital thermometer onto a dishwashing rack and ran the rack through a cycle in the dishwasher. The thermometer displayed the maximum temperature during the dishwashing cycle of 144 degrees Fahrenheit (F). The facility's 'Commercial Rack Conveyor Dish Machine Manufacturer Instructions' dated 6/15/1999 documents the minimum wash temperature for hot water sanitization should be 150 degrees F, the pumped rinse minimum temperature should be 160 degrees F, and the final rinse minimum temperature should be 180 degrees F. On 5/3/23 at 9:09 am, V12, Dietary Aide, stated to V11, Dietary Aide, When I checked the temperature this morning it was 152 (degrees F). V12 then placed the same facility digital thermometer back into the dishwashing rack and ran the rack through another dishwashing cycle. The digital thermometer displayed the maximum temperature during the dishwashing cycle of 146 degrees F. On 5/3/23 at 9:15 am, V10, Registered Dietician, stated, Actually this machine uses chlorine to sanitize, not the high temp (temperature). V10 then ran a dishwashing rack through the machine and used an orange test strip material (actually designed to test quaternary ammonium sanitizer) to check the chlorine content of the rinse water. The orange test strip did not change color at all to indicate the presence of any chlorine during the dishwashing cycle. V10 then stated to V12, We should have the test strips that turn blue. V10 obtained a different container of white test strip material to test the water from the dishwashing cycle and the test strip turned a light gray color to indicate approximately 10 parts per million (ppm) of chlorine. The facility's 'Commercial Rack Conveyor Dish Machine Manufacturer Instructions' dated 6/15/1999 documents the chemical sanitizer required is 50 ppm of chlorine. The facility's dishwasher test log dated from 4/14/23 through 5/3/23 documents the dietary staff only record a check mark in the column for the chlorine test strip, rather than the actual number measured. Neither V12 nor V10 could state how long the dishwashing machine had been too low on chlorine to sanitize the dishes. On 5/3/23 at 9:20 am, V10, Registered Dietician, stated, It's frustrating, (dishwasher maintenance company) fixed this machine about a month and a half ago for the same issue. V10 further stated, We can definitely start recording the number for the chlorine. The facility's 'Resident Census and Conditions of Residents' dated 5/2/23 documents 28 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146049 If continuation sheet Page 4 of 4