Heather Health Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to transcribe physician's orders, failed to follow physician orders, failed to notify the wound care director of resident's skin integrity impairment, failed to ensure that staff were aware of required LALM (Low Air Loss Mattress) settings, failed to ensure that the LALM was on the right setting (while in use), failed to ensure that the LALM was on (while in use), failed to implement preventive interventions, and/or failed to ensure that treatments were administered for two of three residents (R1, R2) reviewed for pressure ulcers. These failures resulted in R2 developing the following (facility acquired) pressure ulcers: sacrum (stage 3), right heel (stage 3), left heel (stage 3), right buttock (stage 2), and left elbow (unstageable). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to document meal intake, failed to provide meal within reach, and/or failed to provide required feeding assistance for two of three dependent residents (R1, R2) reviewed for nutrition. These failures resulted in R2's significant weight loss (-15.6% within 1 month) and R1's significant weight loss (-7.9% within 1 month).

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and maintain a safe environment for one resident that had a diagnosis of schizophrenia, anxiety, and depression, with a documented history of self-harming behaviors and exit-seeking behavior. The facility failed to prevent the resident from accessing a fire extinguisher, which was used to break a second-floor window and exit the building without staff knowledge. This affected one of three residents (R162) reviewed for supervision. As a result, R162 exited through the second-floor window, landed face down outside the facility, and sustained a left leg [NAME] fracture, a severe fracture involving the distal tibia.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow facility policy and infection prevention standards of practice by not conducting contact tracing, failing to immediately conduct testing, implement isolation orders and doffing Personal protective equipment prior to exiting an isolation room after two residents (R1 and R11) and one staff member (V8-Certified Nursing Assistant) tested positive for COVID-19 resulting in resident and staff exposure to COVID-19. This failure has the potential to affect a total of 155 residents at the facility. Findings Include:R11 was admitted to the facility on [DATE] with a diagnosis of ataxia, major depressive disorder, type II diabetes, and hypertension. R11's progress notes document on 3/2/26 that R11 sustained a fall and was sent to the hospital. R11 returned to the facility on 3/2/26 with a diagnosis of covid-19. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its call light policy and ensure call light cords were within reach for 6 residents (R74, R78, R81, R121, R144, and R161) out of 10 residents reviewed for call light accessibility in a sample of 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance at least every two hours for four residents (R10, R98, R115, and R145) dependent or require maximum assistance of staff for incontinence care out of four residents reviewed for ADLs (Activities of Daily Living) in a sample of 50.

Inspectors wroteBased on interview and record review, the facility failed to follow its advance directives policy and ensure one resident's (R2) wishes for advance directives are documented in the physician orders of three reviewed for advance directives in a sample of 50.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of diagnostic test results indicating the need for further evaluation for 1 of 3 residents (R159) reviewed for physician notification.

Inspectors wroteBased on interview and record review, the facility failed to follow their against medical advice policy by not notifying the physician and failing to provide medications for one (R128) resident who left the facility against medical advice for two of three residents reviewed for discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Enoxaparin Solution Injection Solution Prefilled Syringe. Injection 0.4ml was available for administration as prescribed. This affected one of three residents (R86) reviewed for available medication. Findings Include:R86's brief interview for mental status dated 12/11/25 documents a score of fifteen which indicates cognitively intact. R86's physician order sheet dated 12/19/2024 documents: Enoxaparin Solution Injection Solution Prefilled Syringe. Inject 0.4ml subcutaneously two times a day related to chronic embolism and thrombosis of unspecified deep vein of lower extremity. Medication Administration Record dated 3/1/2026- 3/31/2026 documents: Enoxaparin Solution Injection Solution Prefilled Syringe; Wednesday 3/4/26 at 6am, 4pm and on 3/5/26 at 6am documents the number nine (9). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their medication storage policy by having opened, used, undated and unrefrigerated medication on the medication cart for two of three residents (R3 and R5) reviewed for medication storage. Findings Include:On [DATE] at 3:36pm, during medication cart audit with V26 (Nurse), R3's Insulin Glargine Subcutaneous Solution Pen-injector dispensed on [DATE] was opened, used and not dated. V26 said, R3's insulin should have been dated after opening to ensure expired medication is not given. V26 said, insulin is good for twenty-eight to thirty (28-30) days after opening. R5's Insulin Aspart (with Niacinamide) was observed on the medication cart, new and not used or opened. Refrigerate until opened was documented on the pharmacy bag that held R5's insulin. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and homelike environment on one of three 3 units reviewed. On the third locked unit, two lounge chairs located in the television room were observed with multiple old, dried stains on the seat cushions and armrests. Findings Include: On 3/4/26 at 10:09am, two filthy lounge chairs with multiple dried irregular shaped circles in the middle of the seat cushion, discoloration, dirt and other stains covering the chair and arm rest were observed in the resident television room on the third (3rd) unit. V6 (Nurse) said, residents sit in those chairs and watch television. V6 said, those chairs have been dirty for a long time. On 3/4/26 at 10:20m, V3 (Assistant Director of Nursing) said, the lounge chairs have stains on the cushion and arm rest. [...]

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to follow its abuse policy and keep its residents free from abuse. This failure resulted in two residents (R2 and R3) having in a verbal altercation that escalated to a physical altercation before staff intervention out of three residents reviewed for abuse in a sample of 3. R3, with a history of physical aggression, hit R2 in the left eye with his fist. R2 sustained a laceration, bruising, and swelling to left eye.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their maintenance and housekeeping policy and procedures by not maintaining a clean, sanitary, and comfortable environment that is in good repair and by not providing a television for a resident who had been moved to a new room for three weeks. This failure applied to nine of nine residents (R17, R36, R100, R104, R108, R112, R119, R143, and R303) reviewed for environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff administered scheduled medications on time for residents. This failure affected five (R65, R71, R79, R112 and R119) of five residents reviewed for medication administration and has the potential to affect all 31 residents in the west wing of unit 1 at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two residents (R88 and R115) were able to operate their call light by placing it was within reach.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provided post-surgical wound care according to current physician's orders for 1 of 3 residents (R2) reviewed for wounds in the sample of 6; and failed to follow their facility policies on following physician orders for surgical wound care.

Inspectors wroteBased on interview and record review, the facility failed to utilize a gait belt during a transfer for a resident (R2) that requires substantial/maximum assistance for one out of three residents reviewed for falls in a total sample of three. This failure resulted in R2 suffering three fractured ribs after falling to the floor during the transfer. Findings Include: A Nursing note dated 11/13/24 at 1:11PM documents the nurse was notified by the wound care aide that R2 was complaining of exaggerated pain to the right side. R2 stated while being transferred to the wheelchair during the morning get up, balance was lost and subsequently R2 fell to the floor. The nurse was not aware of the incident prior to R2 reporting it. The nurse practitioner was notified and sent R2 out for further evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a physician of a resident (R2) fall until about six hours later when R2 began complaining of new pain for one out of three residents reviewed for physician notification in a total sample of three. Findings Include: R2 is a [AGE] year old with the following diagnosis: history of falling, muscle weakness, and multiple fracture to the right ribs. A Nursing note dated 11/13/24 at 1:11PM documents the nurse was notified by the wound care aide that R2 was complaining of exaggerated pain to the right side. R2 stated while being transferred to the wheelchair during the morning get up, balance was lost and subsequently R2 fell to the floor. The nurse was not aware of the incident prior to R2 reporting it. The nurse practitioner was notified and sent R2 out for further evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that bathroom toilet handlebars and sink were properly installed to prevent from falling on a resident. This failure applied to one (R1) of three residents reviewed for accidents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to protect a cognitively and visually impaired resident's (R1) right to be free from physical abuse from another resident (R2) with known history of aggressive behavior for 1 (R1) of 3 residents reviewed for abuse in a sample of 10. This failure resulted in R1 being physically assaulted by R2. The Immediate Jeopardy began on [DATE] at 04:10 AM when R2 physically assaulted R1 which resulted in R1's emergent hospitalization. V1 (Administrator) was notified on [DATE] at 11:14 AM of the Immediate Jeopardy. The facility presented an acceptable removal plan, and the immediacy was removed on [DATE]. The surveyor conducted onsite investigation on [DATE] to confirm the removal plan was implemented.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide adequate supervision and monitoring on a resident assessed to be at risk for elopement due to history of elopement from previous nursing home; failed to ensure the resident did not leave facility without staff knowledge or supervision; and failed to follow elopement policy on procedures and reporting. These failures affected one (R5) of three residents in a sample of 10 reviewed for elopement risk and supervision. These failures resulted in R5 able to eloped from facility. R5 experienced harm by walking to emergency room without shoes on and having to cross a high-volume traffic intersection at night, while allegedly experiencing chest pain. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide necessary care and treatment during change in condition on a resident complaining of chest pain; and failed to monitor escalation of maladaptive behavior for two (R2 and R5) of five residents in the sample of 10 reviewed for quality of care. This deficiency resulted in R2 exhibiting increased wandering and pacing, resulted R2 to commit an assault behavior. This deficiency also resulted in R5 experiencing severe chest pain, eloped from the facility to go to the nearest emergency room for further evaluation and treatment.

Inspectors wroteBased on interview and record reviews, the facility failed to conduct pain assessment and provide necessary care and treatment on a resident complaining of chest pain. This deficiency affect one (R5) of one resident reviewed for pain. This deficiency resulted in R5 experiencing severe chest pain, eloped from the facility without shoes on, to go to the nearest emergency room for further evaluation and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards of quality by a) failing to protect cognitively and visually impaired resident's right to be free from physical abuse from another resident with known history of aggressive behavior; b) failing to provide adequate supervision and monitoring on a resident assessed to be at risk for elopement; c) failing to ensure resident did not leave facility without staff knowledge or supervision; d) failing to follow elopement policy on procedures and reporting; e) failing to conduct pain assessment and provide necessary care and treatment on a resident complaining of chest pain and during change in condition; and f) failing to monitor escalation of maladaptive behavior. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow manufacturer recommendation in using low air loss mattress to resident who has Stage 4 sacral pressure ulcer. This deficiency affects one (R21) of three residents in the sample of 30 reviewed for Pressure ulcer management.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff. This failure affected one resident (R1) of four residents reviewed for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to follow their Abuse Prevention Policy by not keeping residents free from physical and verbal/mental abused by staff. These failures applied to two (R15, R19) of seven residents reviewed for abuse and resulted in R15 experiencing mental abuse by feeling retaliated against by a staff member and R19 was physically abused by staff hitting R19 with a hanger to the right buttock, leaving a red discoloration.

Inspectors wroteBased on observation, interview and record review, the facility failed to re-evaluate fall care plan interventions for effectiveness after resident falls for residents assessed to be at risk of falling, and failed to have individualized interventions, taking resident cognitive function into account, included in the plan of care to meet specific resident needs to address re-current falls. This failure applied to three (R4, R5, R26) of three residents reviewed for falls and resulted in R4 having multiple falls and sustaining a laceration to the forehead, which required sutures; R5 had a fall which resulted in hospitalization for acute intracranial hemorrhage; and R26 having multiple falls and being observed to wander into other resident rooms unsupervised. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their maintenance policy by 1. not responding to maintenance requests timely 2. not ensuring the residents rooms and communal areas were in good condition and 3. Maintaining Resident room equipment to work properly. These failures affected six (R8, R16, R32, R33, R34, R35) of eleven residents reviewed for homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing coverage, per their assessed staffing needs to ensure adequate care and support. This failure has the potential to affect all 151 residents that reside in the building.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a pressure relieving air mattress was available for a resident with known pressure ulcers upon admission and readmission. This failure affected one (R8) out of three residents reviewed for accommodation of needs related to pressure ulcer treatment and prevention.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its policy related to notification related to a resident room change. This failure applied to one (R11) of three residents reviewed for room transfers.

Inspectors wroteBased on interview and record review, the facility failed to release resident's medical record to resident's guardian/power of attorney as requested. This failure affected one (R5) of one resident reviewed for release of medical records.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its policy related to wound care documentation for residents being treated for pressure ulcers. This failure affected one (R9) of four residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and remove a staff member after an allegation of abuse from all resident care. This affected one of three residents (R1) reviewed for abuse policy. This failure resulted in V5 (Certified aide) to complete her shift after R1 made an allegation of abuse against V5. Findings Include: Facility reported incident dated 8/28/23 reads in part: Daugther of R1 reported that R1 made an allegation concerning delivery of care. Nurse informed daugther of R1 that a thorough investigation will take place as well as report to IDPH (Illinois Department of Public Health). No injury. On 8/30/23 at 2:55PM, V6 (RN) stated that at approximately a little past 8:00PM on 8/28/23, V16 (R1's Family Member) came to V6 at the nurses station and reported a concern regarding the care of a CNA to R1. [...]