Heritage Health-Hoopeston

Inspectors wroteBased on observation, interview, and record review, the facility failed to sanitarily store respiratory equipment when not in use. This failure affects four residents (R5, R27, R40, and R74) out of five residents reviewed for respiratory care on the sample list of 41.

Inspectors wroteBased on interview and record review the facility failed to allow one (R62) resident to utilize their own Continuous Positive Airway Pressure (C-PAP) machine from their home environment out of one resident reviewed for resident rights in a sample list of 41 residents.

Inspectors wroteBased on record review and interview, the facility failed to complete a significant change Minimum Data Set Resident Assessment for a resident with a significant decline in multiple areas of health status. This failure affects one resident (R11) out of one reviewed for activities of daily living on the sample list of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set Resident Assessment Instrument to include the use of non-invasive ventilators (CPAP, Continuous Positive Airway Pressure). This failure affects two residents (R27 and R40) out of five residents reviewed for respiratory services on the sample list of 41.

Inspectors wroteBased on interview and record review the facility failed to follow their Antibiotic Stewardship policy for one (R2) resident out of one resident reviewed for Antibiotic Stewardship in a sample list of 41 residents.

Inspectors wroteBased on interview and record review the facility failed to implement fall interventions to prevent injury for one of three residents (R1) reviewed for falls on the sample list of three. These failures resulted in R1 sustaining a fall which led to a fracture of both the left ulna and left femoral neck.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two of three residents (R1, R2) reviewed for abuse on the sample of four.

Inspectors wroteBased on interview and record review the facility failed to revise a care plan after an incident of resident to resident physical abuse. This failure affects one of three residents (R1) reviewed for abuse on the sample list of four.

Inspectors wroteBased on observation and interview the facility failed to maintain a homelike environment by failing to maintain linen in good condition. This failure affected two of twelve residents (R25, R33 ) reviewed for homelike environment on the sample list of 36. 1. On 7/27/2025 at 10:39 AM R25 stated the towels are worn and have frayed edges and holes. R25 held up a towel with worn, frayed edges and two washcloths with frayed edges on every side. R25 stated she doesn't understand why the staff don't get rid of the worn linen and instead provide linen that is in good shape for residents to wash up with. R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact. 2. On 7/28/25 at 8:06 AM R33 stated the edges of towels get frayed. There was a wet washcloth on bathroom sink with frayed, stringy edges. [...]

Inspectors wroteBased on interview and record review the facility failed to timely report an injury of unknown origin to the physician and resident representative. The facility also failed to report changes in medication orders to the resident representative for two (R1, R2) of six residents reviewed for changes in condition in the sample list of 12.

Inspectors wroteBased on interview and record review the facility failed to report allegations of abuse and timely report an injury of unknown origin to the facility's administrator and the state surveying agency for three (R1, R2, R6) of eight residents reviewed for abuse in the sample list of 12.

Inspectors wroteBased on interview and record review the facility failed to investigate allegations of abuse and to implement protective measures following reported allegations of abuse for three (R1, R2, R6) of eight residents reviewed for abuse in the sample list of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall interventions, document a fall in the medical record, perform safe and proper transfers, and thoroughly investigate falls for three (R1, R2, R6) of three residents reviewed for accidents in the sample list of 12.

Inspectors wroteBased on observation, interview and record review the facility failed to label a refrigerated, plastic container of chopped onions and a refrigerated, plastic container of chopped tomatoes with any dates and failed to monitor temperature cooking times to ensure that food is being served safely. These failures have the potential to affect all 72 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to have orders, consents or assessments for R52 and R219, failed to complete an initial assessment for a soft waist restraint for R47 and failed to obtain a consent for a soft waist restraint for R55 for four of four residents (R47, R52, R55, R219) reviewed for restraints on a sample list of 42 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered and in accordance with manufacturer's instructions for three (R7, R270, R59) of 11 residents reviewed for medication administration in the sample list of 42. This failure resulted in four medication errors out of 25 opportunities, a medication error rate of 16%.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were labeled with the resident's full name and opened dates, ensure medications were not used past the beyond use date, and discard medications for eight (R1, R6, R269, R62, R53, R59, R44, R9) of 18 residents reviewed for medication storage on the sample list of 42.

Inspectors wroteBased on interview and record review the facility failed to obtain a level II PASRR (Preadmission Screening and Review) for one resident (R57) with Post-traumatic Stress Disorder (PTSD) of one resident reviewed for PASRR in a sample list of 42 residents. Findings Include: R57's Minimum Data Set (MDS) dated [DATE] documents R57 has an active diagnoses of PTSD and is cognitively intact. R57's Diagnoses list includes a diagnosis dated 6/30/23 of PTSD. There is no evidence in the medical record the facility obtained a Level II PASSR screening when they became aware of R57's diagnosis of PTSD. On 6/5/24 at 1:00PM V1, Administrator stated I was not aware that if the Level I PASRR did not indicate a Level II we had to get a level II in the event we became aware of a diagnosis of a serious mental Illness. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to shave two (R12 and R17) of two dependent residents reviewed for dependent activities of daily living on a sample list of 42 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to complete a safe sit to stand mechanical lift transfer for one (R55) of four residents reviewed for falls in the sample list of 42.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify potential triggers and implement resident centered trauma based interventions for one resident (R57) with Post-traumatic Stress Disorder (PTSD) of one resident reviewed for PTSD in a sample list of 42 residents. Findings Include: The facility's policy Trauma Informed Care dated 1October 2022 states It is the policy of this facility to ensure that residents who are trauma survivors receive culturally competent, trauma informed care. Resident experiences and preferences will be taken into account in an effort to eliminate or mitigate triggers that could cause retraumatization. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene before and after eye drop and insulin administration for two (R59, R62) of 11 residents reviewed for medication administration in the sample list of 42.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's (R38) primary care physician of repeated refusal to take prescribed medications. This failure affects one resident (R38) of 12 residents reviewed for medication in the sample list of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a significant medication error by leaving eleven ordered morning medications at a resident's bedside. This failure affects one resident (R38) of 12 residents reviewed for medication administration observation in the sample list of 30.