Inspection·April 18, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to timely report an allegation of sexual abuse to the Administrator for two of three residents (R1, R2) reviewed for sexual abuse on the sample list of three. Residents Affected - Few Findings Include: The facility's Serious Injury Incident and Communicable Disease Report dated 4/10/24 at 12:15 pm documents, on 4/9/24 at 12:45 pm, R2 leaned over and kissed R1 on the lips. Since both R1 and R2 have a very low BIMS (Brief Interview for Mental Status) score; R1 being a 1 {indicating severe cognitive impairments} and R2 being a 4 {indicating severe cognitive impairments}, the intervention in place is to make sure that residents are watched and separated to prevent this from happening again. On 4/17/24 at 11:09 am, V1 (Administrator) stated on 4/10/24, V8 CNA (Certified Nursing Assistant) came up to V1 and asked V1 if V1 was aware of what happened on 4/9/24 between R1 and R2. V1 explained V1 was unaware of anything happening, then V8 reported that V8 had been told that R2 kissed R1. V1 stated V8 did not know any of the specifics though and told V1 to talk to V4 CNA(Certified Nursing Assistant), who was present when it occurred. V1 then questioned V4 and V4 reported that V4 was taking R1 to the restroom on 4/9/24 before lunch, around 11:15 am, when R2 approached R1 and kissed R1 and stated, I'm here now or I'm back, something to that affect. V1 explained R1 was in a wheelchair at that time and that V4 intervened and told R2 that R2 couldn't do that, that it was inappropriate. V1 stated V1 educated V4 that V4 should have reported it immediately to V1 because it is reportable and I (V1) am on a timeline to get things reported. V1 explained that V4 has worked at the facility for a long time, so (V4) should have already known that this would be considered a sexual abuse allegation and should have been reported. V4 reported to V1 that V4 reported the allegation to V10 RN (Registered Nurse) when it happened but when V1 spoke to V10, V10 said that the allegation was never reported to V10. On 4/17/24 at 12:02 pm, V4 CNA stated V4 was taking R1 to the restroom by the Nurses Station when R2 came up behind us and said I'm going to be here and bent over and kissed R2 on the lips. V4 explained V4 told R2 that R2's actions were inappropriate and that R2 couldn't be doing that {kissing R1}. V4 stated V4 reported the incident to V10 RN (Regitered Nurse), because V4 was busy and assumed that V10 would have reported the incident to V1 but V10 didn't. V4 explained, the following day, V1 asked V4 about the incident after being told about it by another CNA. On 4/17/24 at 7:49 pm, V10 RN (Registered Nurse) stated V4 did not report the incident of R2 kissing R1 to V10 explaining, if V4 would have, V10 would have immediately reported the incident to V1. (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 3 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 04/18/2024 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)