F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a resident (R1) was not subjected to verbal abuse
by an employee. R1 is one of three residents reviewed for abuse on the sample list of five.
Findings include:
On 10/7/23 at 11:24am V3 Certified Nursing Assistant (CNA) said, on 9/20/23 at 2:00pm V4 Certified
Nursing Assistant (CNA) was preparing R1 for a shower in R1's room. V3 said, V3 heard V4 tell R1 that if
R1 doesn't stop yelling, V4 will drown R1 in the shower. V3 said, V4 gave R1 a shower, and brought R1
back to R1's room. V3 said, V3 than heard V4 tell R1 to shut the (expletive) up, because R1 was yelling out.
V3 said, V3 immediately went and told V2 Director of Nursing (DON).
On 10/7/23 at 1:15pm V1 Administrator said, on 9/20/23 V1 was notified of an allegation of abuse between
R1 and V4 Certified Nursing Assistant (CNA). V1 said, V1 interviewed V3 Certified Nursing Assistant (CNA)
who informed V1 that on 9/20/23 at 2:00pm V4 Certified Nursing Assistant (CNA) was preparing R1 for a
shower, V4 stated V4 was going to drown R1 if R1 didn't stop screaming. V1 said, V3 further informed V1
that upon V4 bringing R1 back to R1's room, V4 told R1 to shut the (expletive) up, because R1 was yelling.
V1 said, V1 interviewed V4 who admitted telling R1 to shut the (expletive) up. V1 said, as the result of the
investigation, it was determined that V4 committed verbal abuse by admitting using inappropriate tone with
R1 and telling R1 to shut the (expletive) up.
R1 Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical
diagnoses; Type 2 Diabetes Mellitus, Hyperlipidemia, Protein-Calorie Malnutrition, Anxiety Disorder, Major
Depressive Disorder, Hypothyroidism, HTN, Osteoarthritis, Noninflammatory Disorders of Uterus,
Pulmonary Fibrosis, Cholelithiasis, Solitary Pulmonary Nodule, Constipation, Dementia, and Abnormalities
of Gait and Mobility.
R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS)
score 0, severe impairment and is total dependence two-person physical assist with all Activities of Daily
Living (ADL).
The Facility's Final Investigation Report dated 9/25/23, for R1 incident which occurred on 9/20/23
documents V4 Certified Nursing Assistant (CNA) was preparing R1 for a shower, V4 reportedly stated V4
was going to drown R1 if R1 didn't stop screaming. Upon returning R1 from the shower to R1's room, V4
reportedly told R1 to shut the (expletive) up, because R1 was yelling.
The Facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property
(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 2
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
10/07/2023
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
revised 12-1-2022 documents, Preface: It is the policy of the facility to encourage and support all residents,
staff, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect,
exploitation, involuntary seclusion, or misappropriation of resident property from abuse, neglect,
misappropriation of resident property, and exploitation. This includes but not limited to freedom from
corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the
residents medical symptoms. i. Verbal abuse is defined as the use of oral, written, or gestured
communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend,
or disability.
Event ID:
Facility ID:
146049
If continuation sheet
Page 2 of 2
