Heritage Health-Hoopeston

In the surveyor’s words

From the most serious findings on record at Heritage Health-Hoopeston, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 28, 2026

  Based 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. Findings include:The facility's Fall Assessment and Management Policy, revised June 2024, documents the facility will assess each resident's fall risk and implement interventions to decrease the residents' risk of falls and subsequent risk for injury.R1's Medical Diagnosis List, dated April 2026, documents R1's diagnoses including Alzheimer's Disease, Dementia with Agitation, Anxiety, and Chronic Pain.R1's Minimum Data Set, dated [DATE], documents R1 as severely cognitively impaired. […]

• Actual harm, isolatedF689Jun 29, 2022

  Based on interview and record review the facility failed to provide continuous supervision for a resident while taking a shower. This failure affects one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 falling in the shower sustaining fractures of the left upper and lower extremities. Findings include: R1's Facesheet dated 6/29/22 documents R1 is diagnosed with Alzheimer's Disease, Dementia with Behaviors, and [CONDITION(S)]. R1's care plan documents focus area of R1 receiving anticoagulant therapy initiated 2/25/20 revision on 2/1/22 with interventions to take precautions and avoid falls. […]

• Actual harm, isolatedF689Apr 27, 2022

  Based on observation, interview, and record review the facility failed to thoroughly investigate falls to identify the root cause and develop appropriate interventions, and failed to implement post fall interventions for six (R2, R9, R29, R41, R52, R56) of seven residents reviewed for accidents in the sample list of 35. The facility failed to implement safety interventions following seizures resulting in falls, this failure resulted in R56 falling and sustaining a left elbow laceration that required sutures. Findings include: 1.) On 4/25/22 at 12:00PM R56 was sitting in a wheelchair in the hallway, dropped R56's drink on the floor, and fell forward. Staff was called for assistance. […]

• Actual harm, isolatedF760Apr 27, 2022

  Based on observation, interview, and record review the facility failed to administer [CONDITION(S)] medications as ordered for one (R56) of seven residents reviewed for accidents in the sample list of 35. This failure resulted in R56 having a [CONDITION(S)] that resulted in a fall with an elbow laceration that required sutures. Findings include: 1.) On 4/25/22 at 12:00 PM R56 was sitting in a wheelchair in the hallway, dropped R56's drink on the floor, and fell forward. Staff was called for assistance. R56 was unresponsive and was having a [CONDITION(S)]: R56's arms and legs were spastic and shaking, R56 was drooling and made a gurgling sounds, R56's eyes were rolled back. Staff transported R56 into R56's room. […]

• Actual harm, isolatedF689Nov 20, 2021

  Based on record review and interview the facility failed to implement care planned fall interventions to prevent a fall for one of three residents (R11) reviewed for falls on the sample list of 13 residents. R11 fell and sustained a displaced spiral humerus (arm) fracture when staff failed to utilize two staff for a transfer and failed to implement nonskid floor strips. Findings include: R11's undated Face Sheet documents an admitted [DATE] and diagnoses of: COVID-19 on 11/9/21, Acute Embolism and [CONDITION(S)] of Deep Veins of Right Lower Extremity and [CONDITION(S)] Right Lower Limb on 11/4/21, Closed Displaced Spiral Fracture of Right Humerus on 11/16/21 and History of Falling and Difficulty in Walking. […]