Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Iroquois Resident Home, The during CMS and state inspections, most recent first.
The facility failed to employ an Infection Preventionist (IP), affecting all 27 residents. During a survey, it was observed that no IP was onsite, and the DON confirmed the absence, as the previous IP left a month ago. The Administrator acknowledged the need for an IP due to residents on antibiotics, those in contact isolation, and staff needing PPE education. The facility's assessment planned for an IP, but this was not implemented.
A resident with pressure ulcers on the buttocks and coccyx was not properly assessed or treated, and the physician was not notified. Despite the resident's complaints of severe pain, no treatment was applied, and the medical record lacked documentation of the ulcers. The DON confirmed that the LPN should have assessed the areas and notified the physician.
Two residents with severe cognitive impairments experienced multiple unwitnessed falls due to the facility's failure to implement effective fall prevention interventions and conduct thorough investigations. Sensor alarms were not in place, and neurological assessments were incomplete or undocumented. The facility's policies on fall prevention and head injuries were not adequately followed, contributing to the repeated falls and potential injuries.
The facility did not follow its Catheter Care Handling policy, which requires catheter tubing and drainage bags to be off the floor. Two residents had their urinary drainage bags improperly positioned, with one bag clipped to a trash can and another hooked to a recliner, both touching the floor and uncovered. The DON confirmed this was against policy.
A resident with severe cognitive impairment and multiple medical conditions was found using side rails without a documented assessment, contrary to facility policy. The MDS Coordinator confirmed the lack of assessment and acknowledged the inappropriate use of side rails.
The facility failed to obtain informed consent, assess the need, and document symptoms for psychotropic medications for three residents. There was no documentation of nonpharmacological interventions or monitoring for side effects. Staff were unclear about responsibilities for psychotropic assessments and consents, leading to deficiencies in medication management.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with medical conditions requiring such measures. A resident with a Gastrostomy tube and two residents with urinary catheter drainage systems did not have EBP signs, PPE, or isolation disposal bins in their rooms. The DON admitted the lack of EBP implementation and policy.
A facility failed to follow its Antibiotic Stewardship Protocol by administering a prophylactic antibiotic to a resident with a history of UTIs. The resident, severely cognitively impaired and diagnosed with Alzheimer's and Dementia, was given Cephalexin daily despite the facility's policy requiring appropriate antibiotic use. The Director of Nurses noted the oversight was due to the absence of an Infection Preventionist and acknowledged the treatment's ineffectiveness as the resident experienced a UTI while on the antibiotic.
A resident with severe cognitive impairment and multiple medical conditions was found with an unsecured bed rail, posing a safety risk. Despite a physician's order for bed rails to aid in mobility and positioning, the rail was observed hanging at a 45-degree angle. A CNA and LPN confirmed the rail's instability, and the Maintenance Director acknowledged the need for its removal.
The facility failed to timely report an allegation of sexual abuse involving two residents with severe cognitive impairments. A CNA witnessed the incident but did not immediately report it to the Administrator, violating the facility's policy and state and federal requirements. The Administrator only became aware of the incident the following day through another CNA.
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents with severe cognitive impairments. The investigation only included statements from the involved residents and three staff members, but no other residents were interviewed, despite the incident occurring in a populated area. The facility's policy requires interviewing all involved persons, which was not followed.
Failure to Employ an Infection Preventionist
Penalty
Summary
The facility failed to employ an Infection Preventionist (IP), which has the potential to affect all 27 residents residing in the facility. During the Annual Licensure and Certification survey, conducted from June 24 to June 26, 2024, it was observed that there was no IP onsite. The Director of Nurses (DON) confirmed that the facility does not currently have an IP, as the previous IP left a month ago. The DON mentioned plans to sign up for an IP class but had not done so yet. The Administrator also confirmed the absence of an IP, acknowledging the benefits of having one, especially given the presence of residents on antibiotics, those in contact isolation, and the need for staff education and monitoring for proper Personal Protective Equipment (PPE) use. The facility's 'Facility Assessment' revised in January 2024, documented the intention to include an IP as a staff member to provide support and care for residents. However, this plan had not been implemented at the time of the survey, leading to the deficiency noted by the surveyors.
Failure to Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, treat, and notify the physician regarding newly acquired pressure ulcers for a resident. On multiple occasions, a Certified Nurse's Assistant observed open areas on the resident's buttocks and coccyx but noted that no treatment had been applied. The resident expressed experiencing severe pain in the affected areas. Upon further examination, multiple stage two pressure ulcers with maceration were identified, yet there was no documentation of an assessment or physician notification in the resident's medical record. Additionally, the Treatment Administration Record indicated an order for an absorbent wound dressing for Moisture Associated Skin Damage (MASD) on the left buttock, but there was no order or treatment documented for the pressure ulcers on the coccyx. The Director of Nursing confirmed that an assessment should have been documented and that the Licensed Practical Nurse should have notified the physician and applied the appropriate treatment after being informed of the condition by the Certified Nurse's Assistant.
Failure to Implement Fall Prevention and Conduct Thorough Investigations
Penalty
Summary
The facility failed to implement effective fall prevention interventions and conduct thorough fall investigations for two residents, leading to multiple unwitnessed falls. Resident R2, who has a history of repeated falls and severe cognitive impairment, experienced two falls on the same day. The first fall occurred when R2 was found on the floor next to his wheelchair, and the second fall happened when R2 leaned forward and fell out of the wheelchair, hitting his head. The fall investigations did not determine the root causes, and the sensor alarms intended for R2's recliner and wheelchair were not in place. Additionally, neurological assessments were initiated but not completed following these incidents. Resident R25, also severely cognitively impaired, experienced two unwitnessed falls in one day. The first fall occurred when R25 was found on the floor after attempting to get out of bed, and the second fall happened later that day, resulting in minor injuries. The fall investigations for R25 did not include root causes, and the use of a scoop mattress was not documented. Furthermore, neurological assessments were either not completed or not documented for these falls. The facility's policies on fall prevention and head injuries were not adequately followed, as evidenced by the lack of thorough fall investigations and incomplete neurological assessments. The facility's failure to implement and document appropriate interventions and assessments contributed to the repeated falls and potential injuries of the residents involved.
Improper Positioning of Urinary Drainage Bags
Penalty
Summary
The facility failed to adhere to its Catheter Care Handling policy, which mandates that catheter tubing and drainage bags be kept off the floor. During observations, it was noted that two residents with urinary catheters had their drainage bags improperly positioned. One resident's drainage bag was clipped to the side of a trash can, with the bottom of the bag resting directly on the floor and uncovered. Another resident's drainage bag was hooked to the side of a recliner, also uncovered, with the bottom touching the floor. The Director of Nursing confirmed that urinary drainage bags should be covered and not in contact with the floor, indicating a deviation from the facility's policy.
Failure to Assess Resident for Side Rail Use
Penalty
Summary
The facility failed to assess a resident, identified as R2, for the use of side rails, which is a requirement before their implementation. R2's medical history includes diagnoses of cellulitis of the right lower limb, chronic obstructive pulmonary disease (COPD), atrial fibrillation, weakness, repeated falls, and altered mental status. The Minimum Data Set (MDS) for R2 indicates severe cognitive impairment and a need for moderate assistance with toileting, bed mobility, and transferring. Despite these conditions, R2's electronic medical record (EMR) lacked documentation of a side rail assessment. On June 25, 2024, R2 was observed in bed with both side rails raised. The following day, the MDS Coordinator confirmed that R2 had never been assessed for side rails and acknowledged that the side rails should not have been in use. The facility's policy requires a side rail rationale screening for all residents using side rails, which was not completed for R2.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to its Psychotropic Medication Protocol policy, resulting in deficiencies related to the administration and management of psychotropic medications for three residents. The policy mandates informed consent, assessment of the need for psychotropic medications, and the use of nonpharmacological interventions. However, the facility did not obtain informed consent for the psychotropic medications prescribed to the residents, nor did it assess the need for these medications or document the symptoms or behaviors warranting their use. Additionally, the facility did not establish care plans for psychotropic medications or monitor for potential side effects. For Resident 231, there was no documentation of parameters for the use of Lorazepam, and the resident was unaware of the medications available for her anxiety and shortness of breath. The Director of Nursing and other staff members were unclear about who was responsible for completing psychotropic assessments and consents. Resident 230's medical record lacked consent for antidepressant medications and did not document symptoms of depression or nonpharmacological interventions. Similarly, Resident 232's record did not include an assessment for Xanax use or documentation of anxiety symptoms and nonpharmacological interventions. The facility's failure to comply with its policy resulted in a lack of proper documentation and oversight for the use of psychotropic medications.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who required them due to their medical conditions. Resident 25 had a physician order for Jevity 1.5 calorie/Fiber liquid to be administered via a Gastrostomy tube (G-tube) and required EBP. However, the resident's room lacked an EBP sign, Personal Protective Equipment (PPE), and isolation disposal bins. Additionally, a Licensed Practical Nurse (LPN) did not wear a PPE gown during a G-tube dressing change for this resident. Residents 230 and 23 both had urinary catheter drainage systems and also required EBP. Similar to Resident 25, their rooms were not marked with EBP signs, and there was no PPE or isolation disposal bins available. The Director of Nurses (DON) acknowledged that the facility had not implemented EBP for these residents and admitted that there was no existing policy for EBP, despite the need for it due to the residents' conditions.
Failure to Follow Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Protocol by administering a prophylactic antibiotic to a resident with a history of urinary tract infections (UTIs). The resident, who is severely cognitively impaired and diagnosed with Alzheimer's Disease and Dementia, was prescribed Cephalexin 250 mg daily starting in December 2023 for recurrent UTIs. The medication was administered throughout June 2024, as documented in the Medication Administration Record. The facility's antibiotic tracking log also noted the prophylactic use of Cephalexin for this resident. The Director of Nurses acknowledged the oversight, attributing it to the absence of an Infection Preventionist to ensure proper documentation and review. Despite the family's insistence on the long-term antibiotic use, the Director of Nurses noted that the resident experienced a UTI while on the prophylactic antibiotic, indicating the treatment's ineffectiveness. The facility's policy requires the right antibiotic for the right indication, dose, and duration, which was not followed in this case.
Unsafe Bed Rail Attachment for Resident
Penalty
Summary
The facility failed to ensure the safe attachment of bed rails for a resident with multiple medical diagnoses, including cellulitis, COPD, atrial fibrillation, weakness, repeated falls, and altered mental status. The resident was documented as severely cognitively impaired and required moderate assistance for toileting, bed mobility, and transferring. A physician order dated March 2024 indicated the need for bed rails for bed mobility and positioning. However, during an observation on June 24, 2024, the resident was found with both legs hanging off the mattress, and the bed rail on the same side was hanging at a 45-degree angle. A CNA and an LPN confirmed the bed rail was not secure, with the CNA noting it was unsafe and the LPN acknowledging it should have been addressed by maintenance. The MDS Coordinator later stated the side rails could pose a trip hazard, and the Maintenance Director confirmed the rails were unsafe and should be removed.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse involving two residents with severe cognitive impairments. On 4/9/24, a resident with a BIMS score of 4 kissed another resident with a BIMS score of 1. The incident was witnessed by a CNA who intervened and informed the resident that the behavior was inappropriate. However, the CNA did not immediately report the incident to the Administrator as required by the facility's policy. Instead, the CNA reported it to an RN, who later denied receiving the report. The Administrator only became aware of the incident the following day through another CNA. The facility's policy mandates that any employee who becomes aware of abuse must immediately report it to the Nursing Home Administrator. The Administrator or designee is then responsible for reporting the abuse to the state agency within two hours. In this case, the delay in reporting the incident violated the facility's policy and state and federal requirements. The Administrator acknowledged that the CNA should have known to report the incident immediately, given their long tenure at the facility.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents with severe cognitive impairments. On 4/9/24, one resident leaned over and kissed another resident on the lips. Both residents involved had very low BIMS scores, indicating severe cognitive impairments. The facility's investigation only included witness statements from the two residents involved and three staff members, but no other residents were interviewed, despite the incident occurring in a populated area near the Nurses Station/Dining Room before lunch. The facility's policy on abuse, neglect, exploitation, mistreatment, and misappropriation of resident property requires identifying and interviewing all involved persons, including witnesses and others who might have knowledge of the allegations. However, the facility did not follow this procedure, as confirmed by the Administrator, who acknowledged that other residents should have been interviewed to determine if they had any concerns or had witnessed inappropriate behaviors by the alleged perpetrator. This oversight led to an incomplete investigation of the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Watseka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Watseka | 1.4 mi | — | 16 | 0 |
| Prairieview Lutheran Home | 13.6 mi | ★★★★★ | 7 | 1 |
| Gilman Healthcare Center | 13.8 mi | ★★★★★ | 0 | 0 |
| La Bella At Clifton | 15.6 mi | ★★★★★ | 0 | 0 |
| Heritage Health-hoopeston | 20.5 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.