Health inspection·April 27, 2022

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident wishes to self medicate, the Interdisciplinary Team (IDT) must assess the residents' cognitive, physical, an visual abilities. If the Interdisciplinary Team determines that the resident is capable, a comprehensive assessment will be conducted to determine the level of the resident's knowledge and ability. The completed assessment will be utilized to establish a baseline for a training program established through the resident care plan to enable the resident to learn and increase his/her independence in self administration of medications. The facility nursing staff is responsible for drug storage and for recording self administration in the residents Medication Administration Record (MAR). Medication Administration policy 1/11/10 documents: Make sure the resident takes the medication. Generally - Do not leave meds (medications) at bedside (may be exceptions through assessment and care planning.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 2 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete an assessment and document alternative interventions attempted prior to implementing a physical restraint for one (R35) of two residents reviewed for restraints in the sample list of 35. Residents Affected - Few Findings include: On 4/25/22 at 9:51 AM, 11:03 AM, 11:28 AM, and 4/26/22 at 8:13 AM R35 was sitting in a wheelchair with a lap cushion across R35's lap. On 4/27/22 at 11:06 AM V4 Registered Nurse stated R35 has difficulty following commands, and if R35 is in the right mindset R35 tries to remove R35's lap cushion. V4 approached R35 who was sitting in the hallway in a wheelchair with a lap cushion. V4 asked R35 to remove the lap cushion, and R35 did not attempt to remove the lap cushion. V4 stated V4 has not witnessed R35 self remove the lap cushion. R35's Minimum Data Set, dated [DATE] documents R25 has short and long term memory impairment, and R35 is severely impaired with daily decision making. R35's Care Plan dated 3/15/22 documents R35 uses a lap cushion in the wheelchair due to poor safety awareness and a history of falls. R35's Physician's Orders documents an order dated 3/14/22 for a lap cushion when in the wheelchair, and release during meals. There is no documentation in R35's medical record that an assessment was completed for R35's use of the lap cushion in the wheelchair. R35's Restraint Consent dated 3/14/22 documents a verbal consent to use a lap cushion physical restraint for a medical diagnoses of dementia and poor safety awareness. This consent documents a list of alternative interventions, but does not identify which interventions were used for R35 previously. On 4/27/22 at 10:49 AM V26 Assistant Director of Nursing(ADON) stated V26 completes restraint assessments. V26 stated V21 (R9's Power of Attorney) requested the use of the lap cushion since R9 recently started to self propel R9's self in the wheelchair more and had falls. V26 stated the facility had offered a soft lap belt, but V21 requested the lap cushion. V26 was unsure if the soft lap belt was trialed before implementing the lap cushion. V26 provided a copy of R35's Restraint Elimination Review dated 3/14/22 and 4/18/22. This review documents an assessment that determines if the resident is a candidate for restraint reduction. V26 confirmed the review provided was not an assessment and did not include alternate interventions used prior to the lap cushion. V26 stated physical device assessments are completed upon implementation and quarterly under the assessments tab in the resident's electronic medical record. V26 confirmed there was no assessment for the lap cushion in R35's medical record. The facility's Restraint Program Policy and Procedure dated 11/10/15 documents: 1. Prior to the use of any restraint, (unless the restraint is used in an emergency situation) each resident is assessed for potential alternatives by using the restrain Pre-Restraining and Quarterly Evaluation UDA (User Defined Assessment). 2. Documentation of alternatives are then listed in the resident's plan of care. 6. Reduction attempts are documented. Some examples of interventions may include, but are not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 3 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0604 limited to: a. Therapy consultation b. Environmental modifications c. Positioning d. Activity programming e. Toileting programming. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 4 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to initiate a resident centered care plan to address wandering for one resident (R16) of 17 residents reviewed for care plans in a sample list of 35. Findings include: R16's Progress Notes dated 7/27/22 includes the following diagnoses: Alzheimer's Disease, Adult Failure to Thrive, and Deafness. R16's Minimum Data Set (MDS) dated [DATE] includes wandering behavior. R16's Exit Seeking./Wandering assessment dated [DATE] documents 1. Is the resident physically able to leave the building on their own? 1. Yes 2. Is the resident disoriented to place? 1. Yes 3. Does the resident have impaired decision making? 1. Yes 6. Is there a history of wandering? 1. Yes 7. Is there a current behavior of wandering? 1. Yes. R16's progress note dated 3/22/22 at 9:35PM documents (R16) was found exiting the room of another resident, covered in essential oil at 6:50PM. Due to the possibility that resident may have ingested it, poison control was called at 7:00PM. Poison control wanted resident to be observed for upset stomach and/or vomiting. Provider called at 7:08PM and informed of incident and about poison control already being aware. Power of Attorney called at 7:27PM and informed. On 04/26/22 at 4:06 PM V8 , Licensed Practical Nurse (LPN) stated (R16) went into another resident's room. We didn't witness her going in just coming out. (R16) had essential oils on her clothes, I could smell it on her hands. I put my face near her mouth to see if I could smell it. I notified poison control, Power of Attorney, physician, and hospice. I'm not sure if (R16) ingested any. The smell was overpowering and I wasn't able to tell. It was not toxic per poison control, to monitor for nausea. (R16) never had any symptoms that night. I'm not sure what was decided as far as the (essential) oils, I know she still has the wax melts. We just have to monitor to make sure (R16) doesn't go into other resident's rooms. She wanders, but has never exhibited any exit seeking or sounded door alarms. (R16) usually goes down the hall and into resident's rooms. We check the functioning of the wander guard every shift, the nurse does it. We use the remote to test. (R16) wears a wander guard. At this time, R16 was standing in the hall wearing wander guard to her ankle. R16's Care Plan reviewed 3/22/22 does not address wandering. 1/28/22 intervention documents (R16) walks independently without a device but needs supervision as (R16) is unaware of personal space in others rooms. The facility's policy Care Plan revised November 2017 states A comprehensive Person-centered Care Plan will be developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs, while honoring the resident's right to choice. This Care Plan shall include goals, measurable objectives, and interventions to meet identified resident needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 5 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to disinfect a blood glucose meter after use. This failure has the potential to affect six (R212, R213, R27, R40, R1, R14) of six residents reviewed for infection control in the sample list of 35. Residents Affected - Some Findings include: On 4/25/22 at 4:10 PM V17 Licensed Practical Nurse obtained R27's blood glucose of 138. V17 used an alcohol pad to wipe down the machine after use and placed it into the top drawer of the medication cart. On 4/25/22 at 4:17 PM V17 stated the blood glucose machine is shared between residents on the medication cart. V17 confirmed V17 used an alcohol pad to wipe down the machine. On 4/26/22 at 2:31 PM V2 Director of Nursing stated blood glucose machines should be disinfected with a bleach disinfectant wipe after use, and not an alcohol wipe. On 4/27/22 at 8:43 AM V2 provided a list of residents (R212, R27, R40, R213, R1, and R14 ) who share the blood glucose monitor used for R27. The April 2022 Medication Administration Records for R212, R27, R40, R213, R1, and R14 document these residents receive routine blood glucose monitoring and all reside on the same unit. The facility's Blood Glucose Testing and Monitoring policy dated 2/2016 documents to clean the glucometer with a dispatch wipe after use when sharing glucometers between residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 6 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement a restorative walking program for one (R9) of two residents reviewed for limited range of motion in the sample list of 35. Findings include: R9's Minimum Data Set, dated [DATE] documents R9 has a Brief Interview for Mental Status Score of 12 (the high end of moderate cognitive impairment), R9 requires limited assistance of one staff person for walking in the room and the corridor, and requires extensive assistance of one staff person for transfers. R9's Care Plan dated 1/19/22 documents R9 has an activity of daily living performance deficit. This Care Plan includes an intervention for a restorative ambulation program to walk with one staff assist and use of wheeled walker 50 feet three times daily. R9's Physical Therapy Discharge summary dated [DATE] documents upon discharge R9 was able to walk 150 feet with a wheeled walker and contact guard assist. This summary documents To facilitate patient maintaining current level of performance in order to prevent decline, development and instruction in the following RNPs (Restorative Nursing Programs) has been completed with the IDT (Interdisciplinary Team): ambulation and transfers. R9's Restorative Documentation Report for March and April 2022 documents an entry of Not Applicable 25 times in March and 24 times in April for walking 50 feet three times daily. There is no documentation on three entries on dayshift in April. These reports document R9 refused ambulation four times in March and five times in April. R9's Restorative Program and Evaluation Note dated 4/25/2022 at 12:28 PM documents R9 often refuses to walk, staff will continue to encourage R9 to walk, but maintain R9's choice to refuse. On 4/25/22 at 3:01 PM R9 was sitting in a wheelchair in R9's room. R9 stated R9 admitted to the facility due to a fractured hip. R9 used to receive therapy and was walking with therapy staff. After therapy discharged R9, no one walks with R9 anymore. R9 primarily uses a wheelchair, and R9 would like to be walked. On 4/26/22 at 12:06 PM V13 Certified Nursing Assistant (CNA) stated: V13 was assigned to R9's hallway on 4/25/22, and V13 does not usually work on R9's hall. R9 has a walking program, but R9 only takes a few steps during transfers. R9 usually refuses to walk. V13 did not attempt to walk R9 on 4/25/22 since R9 usually refuses. On 4/26/22 at 4:50 PM V24 and V25 CNAs entered R9's room and transferred R9 from the bed to a standing positioning with a gaitbelt. R9 initially refused to walk. V24 and V25 encouraged R9 to walk. R9 walked from the bed, down the hallway, and back to R9's room with a wheeled walker, gait belt, assistance from V24/V25, and a wheelchair followed behind R9. V24 stated We try to walk (R9) every day, it just depends on how much staff we have. On 4/26/22 at 3:25 PM V26 Assistant Director of Nursing reviewed R9's restorative program documentation and confirmed staff documented not applicable. V26 stated: V26 oversees the restorative programs. R9 has a restorative program to walk 50 feet three times daily with a wheeled walker and one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 7 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0688 assist. R9 often refuses to walk. The CNAs should document resident refusals on the electronic restorative charting. V26 will need to educate the CNAs to mark resident refusal instead of not applicable. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 8 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R52's Physician Orders dated 4/27/22 documents diagnoses including Dementia without Behavioral Disturbance, Urinary Incontinence, Chronic Obstructive Pulmonary Disease, Osteoporosis and Malnutrition. R52's Minimum Data Set (MDS) dated [DATE] documents R52 has moderately impaired cognition and requires extensive assistance of two staff for transfers and toileting and R52 does not walk. This MDS documents R52's balance during transitions is not steady and only able to stabilize with staff assistance with moving from a seated to a standing position, getting on and off the toilet and surface to surface transfers. R52's Care Plan dated 8/18/21 documents, Place alarm on bathroom door and make sure it is on when door is closed so that if I (R52) attempt to take myself (R52) to the bathroom the alarm will sound. R52's Fall Investigation dated 2/23/22 documents R52 was observed on R52's bottom in the bathroom next to the locked wheelchair. R52 received scratches on R52's back. No bleeding, bruising or swelling. The root cause documented for this fall is documented as, (R52) transferred self to toilet and lost balance while wiping. The intervention documented for this fall is, alarm on bathroom door changed out for louder alarm, education provided to staff to ensure it is activated at all times. On 4/27/22 at 11:40 AM, V2 Director of Nursing confirmed R52's bathroom alarm is suppose to be on, and confirmed that for R52's fall on 2/23/22 the bathroom alarm was not on and did not sound. V2 stated that staff should have been checking to make sure the bathroom alarm was on during rounds. 5.) R2's Physician Orders dated 4/27/22 documents diagnoses including Anemia, Hypertension, Rheumatoid Arthritis, Unspecified Dizziness and Giddiness, Atrial Fibrillation and Dementia with Behavioral Disturbance. R2's MDS dated [DATE] documents R2 has moderately impaired cognition and requires one person assistance to transfer and use the toilet. R2's balance during transitions documents R2 is unsteady and only able to stabilize with staff assistance with walking and turning around. R2's Care Plan dated 6/7/21 documents R2 is at risk for falls due to weakness and lack of safety awareness due to Dementia. This Care Plan documents an intervention dated 6/7/21 and revised on 12/2/21 for an alarm placed on the bathroom door to alert staff of resident trying to take self to the bathroom. On 4/26/22 at 11:10 AM, R2 was lying in bed and the bathroom alarm is turned off and the bathroom door is closed. On 4/27/22 at 7:49 AM, R2 was lying in R2's bed and the bathroom alarm is missing the cover to it exposing the batteries and the alarm is turned off. On 4/27/22 at 10:53 AM, V12 Certified Nursing Assistant confirmed R2's bathroom alarm was off and stated that V12 must have forgotten to turn it back on after R2's shower. On 4/27/22 at 11:40 AM, V2 confirmed R2's bathroom alarm is suppose to be turned on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 9 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0689 6. R29's Progress Notes dated 4/27/22 includes the following diagnoses: Dementia, Muscle Wasting and Atrophy, Difficulty Walking, Right Wrist Fracture, and Osteoporosis. Level of Harm - Actual harm R29's Minimum Data Set (MDS) dated [DATE] document R29 is independent with Activities of Daily Living. Residents Affected - Few R29's Care Plan includes the following: (R29) is at risk for falls related to weakness and confusion. (R29) had a recent fall that resulted in a bruise on right side of forehead, scalp laceration, right wrist Skin Tear, and Right wrist fracture. Date Initiated: 08/06/2021 Revision on: 03/31/2022. (R29) will resume usual activities without incident through the next review date Date Initiated: 08/06/2021 Revision on: 02/23/2022 Target Date: 05/30/2022 Assist (R29) to keep non-skid footwear on at all times while up Date Initiated: 08/06/2021 Education provided to allow staff to care for other Residents instead of attempting to provide assistance/care for her friends. Date Initiated: 03/18/2022 (R29) was educated that if she drops something to ask staff to pick it up Date Initiated: 02/21/2022 Make sure call light is always within reach Date Initiated: 08/06/2021. Please do not place bed all the way to the floor, as resident is independent it needs to be at proper height so that she can get to a standing position easily. Date Initiated: 02/15/2022 educate to use call light and ask for assistance. Staff is able to assist with adjusting bed to residents liking and safety. Date Initiated: 02/22/2022. R29's Progress Note dated 2/15/22 at 1:05AM documents (R29) found on the floor in the middle of the hallway in front of her room. Resident stated she was doing her hair and fell out of bed onto her head. During neurological assessment resident stated she was seeing double and was lightheaded. 911 was called. They departed facility at 12:43AM. Resident is documented as returning to facility without injury later 2/15/22. Facility's Full Occurrence Report dated 2/15/22 does not identify a root cause for R29's fall. R29's Progress Note dated 2/16/22 at 3:10PM documents (R29) in dining room for activities with Power of Attorney (POA). Reported that resident dropped tissue box under the table and bent over to pick it back up. Upon rising, resident lost balance and landed on buttocks. Resident's POA helped resident backup and into dining chair. Facility's Full Occurrence Report dated 2/16/22 at 3:10PM documents root cause as Bending over caused (R29's) balance to be off. Underlying causes for loss of balance were not assessed. R29's Progress Note dated 3/16/22 at 5:35PM documents (R29) observed on floor of (other resident's room). States she tripped on wheelchair leg and lost balance and fell. States she landed on her right buttocks. Denies injury or pain. Laying on back with head on pillow. Full Range of Motion to all extremities without difficulty. No redness or bruising to right buttock. Stood up with assist x 2 (staff members). Able to bear weight without difficulty. Taken back to room and resting in chair. Alert,oriented as before with occasional confusion. POA and physician notified. No new orders received. VS:98.1 91 16 144/72 with O2 sat 98%. Facility's Full Occurrence Report dated 2/16/22 does not identify a root cause for R29's fall. R29's Progress Note dated 3/30/22 at 1:35PM documents resident heard yelling for help in hallway. Resident found in hallway lying on right side on floor. Upon observation, laceration noted on right side of forehead, skin tear noted on right wrist. R29's Progress Note dated 3/30/22 at 4:40PM documents (R29) returned to the facility from emergency room at 4:20PM. Right wrist is fractured. Facility's Full Occurrence Report dated 3/30/22 at 1:40PM documents root cause as (R29) did not pick her foot up causing a stumble. Underlying causes for loss of balance or unsteady gait were not assessed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 10 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few On 3/27/22 at 3:00PM V2, Director of Nursing stated that the root cause analysis needs to include underlying causes of falls not just circumstances surrounding falls and that a complete fall investigation requires a complete root cause analysis. The facility's policy Fall Assessment and Management revised April 2019 states Interventions will be based on the fall risk assessment,and the circumstances surrounding the risk for injury or actual injury or fall. Some examples may be: Fall related to gait or balance deficit, Falls related to confusion, Falls related to positioning problems, Falls related to toileting needs, Falls related to syncopal episodes, Falls related to environmental hazards, Falls related to sensory/perceptual problems, Falls related to poor judgement or knowledge deficit. 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. R56 was unresponsive and having a seizure: R56's arms and legs were spastic and shaking, R56 was drooling and made a gurgling sounds, and R56's eyes were rolled back. Staff transported R56 into R56's room. On 4/25/22 at 2:50 PM R56 stated R56 has a history of falling out of R56's wheelchair due to seizures, resulting in R56 being treated at the hospital. R56 was asked what the facility has done to keep R56 safe from injury during the seizures. R56 stated I'm just on heavy medications. R56's Minimum Data Set (MDS) dated [DATE] documents R56 is cognitively intact. R56's Care Plan dated 9/1/20 documents R56 has a seizure disorder and includes an intervention dated 2/15/22 to continue to try and provide a safe environment and prevent injuries during seizure activity. R56's Care Plan dated 4/5/22 documents R56 is at risk for falls due to R56's seizure disorder, and includes an intervention dated 3/7/21 to encourage R56 to notify staff when R56 feels a seizure coming on so that staff can potentially be with R56 and provide a safe area. R56's Nursing Notes document the following: On 4/26/2021 at 8:00 AM R56 had a seizure, fell forward out of R56's wheelchair, and hit R56's face on the floor. R56 had a 1 cm (centimeter) laceration to the left eyebrow, and a 3 cm soft tissue injury to the right forearm. R56's nose was swollen, bleeding, and bruising. R56 was sent to the emergency room for evaluation. On 4/28/2021 at 1:03 PM the IDT (Interdisciplinary Team) discussed R56's fall. R56's fall was discussed with R56. R56 said R56 felt the seizure coming on, but couldn't reach the call light in time to call for staff assistance. R56 was told it is ok to yell for help in an emergency situation. The root cause of R56's fall was the seizure, interventions continue per R56's plan of care, and provide safety during seizures. On 8/10/21 at 6:20 AM R56 was in R56's wheelchair, fell to the floor, and began to seize. R56 seized for 45 seconds to 1 minute. R56 had blood noted to both nostrils, an abrasion to the knee, and a 1 inch skin tear to the left elbow. R56 was sent to the emergency room and received two sutures to the left elbow. On 8/12/21 the IDT reviewed R56's fall and post fall interventions were to try and keep R56 safe and prevent injuries during seizures. On 2/14/22 at 7:05 AM R56 was found on the floor of R56's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 11 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few room, hallway under R56's bed. R56 had a seizure and fell out of R56's wheelchair. On 2/15/22 the IDT reviewed R56's fall. The root cause of the fall was that R56 had a seizure while in the wheelchair. The interventions were to obtain Keppra level and Basic Metabolic Profile, and continue to try and provide a safe environment and prevent injury during seizures. There is no documentation that safety interventions were developed and implemented following R56's falls on 4/28/21, 8/10/21, and 2/14/22. R56's Hospital Summary dated 8/10/21 documents R56's Encounter Diagnoses were seizure and left elbow laceration, and to remove R56's left elbow sutures in 10 days. On 4/25/22 at 1:26 PM V4 Registered Nurse (RN) stated: R56 has a history of seizures. We monitor R56's Keppra levels and adjust R56's seizure medications. We count on the medication to keep R56 safe. V4 confirmed no other safety interventions or seizure precautions are used. On 4/27/22 at 11:50 AM V4 stated: V4 was working when R56 fell in August 2021. R56 had a seizure and fell forward out of R56's wheelchair onto the floor. R56 was bleeding from the nose and had skinned up R56's elbow. R56 was sent to the hospital and received two stitches to the left elbow. On 4/27/22 at 10:31 AM V2 Director of Nursing (DON) stated R56's seizure and fall interventions are that R56 takes Keppra for seizures, and R56's Keppra level is monitored. V2 stated R56 has been instructed to alert staff if R56 feels a seizure coming on, and we try to have a safe area when R56 is seizing. V2 confirmed no safety interventions were developed/implemented after R56's seizures and falls. 2.) R9's MDS dated [DATE] documents: R9 has a Brief Interview for Mental Status score of 12, indicating R9 is at the higher range for moderate cognitive impairment. R9 requires extensive assistance of one staff person for transfers and toileting, and R9 is frequently incontinent of bowel and bladder. R9's Fall Investigation dated 3/21/22 documents: R9 was found on the bathroom floor at 2:50 PM. R9 was last observed at 2:20 PM sleeping, and N/A (Not Applicable) is listed as the last time R9 was toileted. Residents (R9) is alert with confusion. (R9) does not recognize (R9's) limitations. (R9) needs one assist for transfers and ambulation. Root Cause: Resident (R9) took self to the bathroom and lost balance and fell. Intervention: Alarm placed on bathroom door to alert staff to attempts at self transferring/toileting. R9's Care Plan dated 1/19/22 documents R9 is at risk for falls, and includes an intervention dated 3/22/22 for an alarm on the bathroom door to alert staff that R9 is attempting to self toilet. R9's Care Plan dated 1/26/22 documents R9 is incontinent of bowel and bladder, R9 wears incontinence briefs, and includes an intervention dated 1/26/22 to change R9's brief every shift and as needed. There is no documentation to assist R9 with toileting regularly. On 4/25/22 at 3:01 PM R9 stated staff had disconnected R9's bathroom alarm this morning when R9 was given a shower, and the staff must have forgot to turn the alarm back on. At this time R9's bathroom door was opened. There was an alarming device at the top of the door with a switch in the off position, and the alarm did not sound. R9's bathroom contained a shower. On 4/25/22 at 4:49 PM R9's bathroom door alarm was not turned on, and the alarm did not sound when the door was opened. On 4/26/22 at 8:10 AM R9 stated the staff never turned the bathroom alarm back on last night. R9's bathroom alarm switch was in the off position, and the alarm did not sound when the door was opened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 12 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0689 On 4/26/22 at 10:50 AM V7 MDS Coordinator was in R9's room. V7 confirmed R9's bathroom door alarm was not turned on. Level of Harm - Actual harm Residents Affected - Few On 4/27/22 at 1:15 PM V2 DON confirmed R9's fall investigation for the 3/21/22 fall does not document the last time R9 was toileted prior to the fall. V2 stated: R9 does require assistance with transfers and toileting, but R9 tries to self toilet and transfer at times. R9's post fall intervention was to use the bathroom door alarm. 3.) R41's MDS dated [DATE] documents R41 is cognitively intact, and requires extensive assistance of two staff for transfers and walking in R41's room. R41's Care Plan documents R41 is at risk for falls and has impaired balance. R41's Care Plan includes interventions to encourage R41 to have R41's feet elevated in the recliner, staff to check on R41 hourly and offer toileting, and to place the wheelchair in front of R41 when sitting in the recliner. R41's Fall Investigations document the following: On 3/2/22 at 9:30 PM R41 was found on the floor near R41's recliner. R41 said R41 was sleeping prior to the fall and did not know how R41 ended up on the floor. R41 had a bump to the ride side of the head with a gash 1.5 cm in length. R41 had a 5.5 cm by 2.5 cm skin tear. The intervention was to place the wheelchair directly in front of R41 when sitting in the recliner. On 3/4/22 at 8:15 AM R41 was found on the floor in between two recliners in R41's room. R41's right forearm skin tear reopened. R42 told staff that R41 was sleeping in the recliner and fell onto the floor. The intervention was to encourage R41 to elevate R41's feet when sitting in the recliner. There is no documentation that R41's wheelchair was in front of R41's recliner prior to the fall. On 3/4/22 at 2:15 PM R4 fell and had a laceration to the right ear. R41 was sleeping in the recliner and fell. There is no documentation that R41's wheelchair was positioned in front of R41 at the time of the fall. On 4/12/22 at 1:00 AM staff responded to R41's call light and found R41 sitting on the floor in front of R41's recliner. R41 often refuses to elevate R41's legs in the recliner. The fall intervention was staff were educated if R41 refuses to have R41's feet elevated when in the recliner, place the wheelchair directly in front of R41. The root cause of R41's falls is that R41 was sleeping and fell from the recliner. On 4/25/22 at 10:12 AM R41 was asleep in the recliner and R41's feet were not elevated. R41's wheeled walker was positioned in front of the recliner. On 4/26/22 at 1:42 PM R41 was asleep in the recliner and leaning to the left. R41's left arm was draped over the arm rest, and R41's feet were not elevated. R41's wheelchair was in the hall way, and R41's wheeled walker was not positioned in front of the recliner. On 4/27/22 at 8:21 AM R41 was asleep in recliner, and R41's feet were not elevated. R41's wheelchair was in the hallway, and R41's wheeled walker was near the bathroom door. R42 (R41's Spouse) stated: R41 prefers to sleep in the recliner. R41 has slid to the floor and fell forward out of the recliner. 4/26/22 at 1:44 PM V13 Certified Nursing Assistant (CNA) stated R41 refuses to elevate R41's legs while sitting in the recliner. V13 was asked what is done if R41 refuses to elevate R41's legs, and V13 replied nothing. On 4/27/22 at 1:15 PM V2 DON reviewed R41's fall investigations and confirmed R41's fall intervention for fall on 3/2/22 was to place the wheelchair in front of R41's recliner. V2 confirmed the wheelchair was not positioned in front of R41's recliner during R41's falls on 3/4/22 and 4/12/22. V2 stated: Staff were educated to position the wheelchair in front of R41's recliner after the fall on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 13 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0689 4/12/22. R41's falls usually occur while R41 is sleeping in the recliner, and R41 refuses to elevate R41's legs. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 14 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to consider dietician recommendations for nutritional supplements, and failed to identify and report significant weight loss to the family and physician for two (R9, R35) of four residents reviewed for nutrition in the sample list of 35. Residents Affected - Few Findings include: 1.) R9's Minimum Data Set (MDS) dated [DATE] documents R9's Brief Interview for Mental Status score is 12 (the high range for moderate cognitive impairment), and R9 weighed 114 pounds. This MDS does not document R9 has had a significant weight loss. R9's Care Plan dated 1/19/22 documents the following: R9 is at risk for nutritional problems and receives a mechanically altered diet. Interventions include to notify the physician for significant weight loss of 3 lbs (pounds) in one week, and greater than 5% in one month, 7.5% in 3 months, and 10% in six months; serve 60 cm (cubic millileters) of nutritional supplement three times daily; and have the Registered Dietitian evaluate and make dietary recommendations as needed. R9's Care Plan has not been updated to reflect R9's weight loss. R9's Weight Log ranging from 12/7/21- 4/26/22 documents the following weights: 124.6 lbs (pounds) on 12/7, 121.6 on 12/9 (3 lb loss in 3 days), 113.8 lbs on 1/18 (8.67% loss since 12/7), and 113.1 on 4/6/22 (9.23% loss since 12/7). There is no documentation in R9's medical record that R9's Physician (V15) or R9's Power of Attorney (V18) was notified of R9's significant weight loss. R9's Nursing Notes document the following: On 12/13/21 orders were received to discharge R9 home. R9 readmitted to the facility on [DATE]. On 4/13/2022 at 2:02PM V19 Registered Dietitian (RD) Note documents R9 has a BMI (Body Mass Index) of 16.2 indicating R9 is underweight, and R9 triggered a weight loss of 10.5 %, 13.3 lbs, since December 2021. R9's weight continues to trend down at one and three months. V19 recommended increasing R9's nutritional supplement to 90 cc three times daily. R9's April 2022 Medication Administration Record (MAR) documents R9 receives a nutritional supplement 60 cc three times daily. There is no documentation that V19's recommendation to increase the supplement to 90 cc three times daily was followed up with V15 Physician or implemented. On 4/25/22 at 2:53 PM R9 stated R9 has lost weight terrible, and R9 takes a nutritional supplement two or three times a day. R9 stated R9 likes the supplement and it tastes good. On 4/25/22 at 3:30 PM V3 Licensed Practical nurse administered 60 cc of nutritional supplement to R9. V3 stated R9 gets 60 cc of the nutritional supplement. On 4/26/22 at 11:48 AM R9 was feeding R9's self in the dining room. R9 was served a mechanical soft diet as ordered and ate about half of the meal. 2.) R35's MDS dated [DATE] documents R35 has short term and long term memory loss, and R35's weight was 133. This MDS does not document R35 has had a significant weight loss. R35's Care Plan dated 6/28/21 documents R35 has had an unplanned weight loss and includes an intervention to give supplements as ordered. R35's Physician's Orders documents an order dated 3/12/21 for a frozen nutritional supplement twice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 15 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few daily. R35's April 2022 MAR does not document R35 receives the frozen nutritional supplement twice daily as ordered. R35's Weight Log documents R35's weights as follows: 144.5 on 7/2/21, 146.2 on 8/2, 147.4 on 8/31/21, 148 on 9/2/21, 150.7 on 9/7/21, 137.1 on 9/21/21 (9.02% loss since 9/7), 138.2 on 10/7/21 (8.29% loss in one month), 141.2 on 11/4/21, 142 on 12/2/21 , 134.8 on 1/13/22 (5.07% loss in one month), 133.3 on 2/2/22, 135.2 on 3/2/22, and 135 on 4/2/22. There are no other documented weights between 9/7/21 and 9/21/21, and between 9/21/21 and 10/7/21. There is no documentation that R35's POA (V21) and V22 Physician were notified of R35's weight loss noted in January. R35's Nutrition Notes record by V19 RD documents the following: On 10/8/21 R35 triggered a significant loss of 8.3 % in one month. The exact origin of weight loss was unsure, and was possibly due to a scale error. On 1/18/22 R35 triggered for a significant weight loss of 10.6 % loss from 9/7/21 to 1/13/22 due to a possible scale error. R9's weight has fluctuated from 134-144 at 1, 3,and 6 months. On 2/16/22 R35 triggered for a significant weight loss of 11.5% from 9/7/21-2/2/22. On 3/17/22 R35 triggered a significant weight loss of 10.4% in 6 months. R35's weight has been stable at one and 3 months. All of these notes document R35's diet (which included a frozen nutritional supplement twice daily) remained appropriate for R35. There were no new nutritional recommendations. On 4/25/22 at 11:20 AM R35 was served the noon meal in individual dishes given one dish at a time. On 4/26/22 at 11:33 AM until 12:04 PM R35 was served the noon meal in individual dishes. R35 fed R35's self. R35 was not served a frozen nutritional supplement at the noon meal on 4/25/22 and 4/26/22. On 4/25/22 at 12:08 PM V23 Certified Nursing Assistant (CNA) stated R35 had been served all of the noon meal, and R35 ate all of the food served. V23 stated the nurses tell the CNAs which residents are to be given a frozen nutritional supplement, or dietary staff will put the supplements on the resident's meal trays. V23 was asked which resident receive a frozen nutritional supplement at lunch, and did not mention R35. On 4/26/22 at 12:10 PM V13 CNA pushed R35 in a wheelchair out of the dining room. V13 stated R35 is offered ice cream only when R35 does not eat R35's meal. On 4/26/22 at 4:43 PM V8 Licensed Practical Nurse(LPN) stated the nurses are responsible for ensuring the frozen nutritional supplements are administered. V8 stated R35 does not have a frozen nutritional supplement ordered to be given on second shift, and nutritional supplement intakes are recorded on the resident's MAR. R35's orders were reviewed with V8 and verified R35 has an order for a frozen nutritional supplement twice daily. V8 confirmed R35's MAR does not document R35's frozen nutritional supplement is administered twice daily as ordered. On 4/27/22 at 11:10 AM V7 MDS Coordinator reviewed R9's and R35's weights, confirmed documented significant weight loss, and confirmed R9's and R35's MDS do not code significant weight loss. V7 stated R9 had discharged from the facility in December 2021, readmitted in January 2022, and V7 was not aware that weight loss prior to admission should be coded on the MDS. V7 stated we thought there was a scale issue with R35's weight on 9/7/21. V7 confirmed R35's weight on 8/2/21, 8/31/21, and 9/2/21 were similar to the 9/7/21 weight. On 4/27/22 at 10:42 AM V2 Director of Nursing stated: The Registered Dietitian prints and gives nutritional recommendations to V20 Dietary Manager and V2. follows up with the physician. V20 is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 16 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0692 Level of Harm - Minimal harm or potential for actual harm responsible for notifying the resident's family and physician of weight loss, and this would be documented in a progress note. R35 is scheduled to get a frozen nutritional supplement with lunch and supper. V2 confirmed R9's weight loss and nutritional recommendations noted on 4/13/22. On 4/27/22 at 1:15 PM V2 stated V2 had no documentation to provide that R9's nutritional recommendation from 4/13/22 was followed up on, or that R9's and R35's families and physicians were notified of weight loss. Residents Affected - Few The facility's Weight Management policy dated February 2016 documents the following: A resident with a weight loss or gain of five pounds will be re-weighed for accuracy. Residents weights will be reviewed at least monthly to identify weight changes. A weight loss of 5 % or more in one month or 10 % or more in six months is considered significant. Residents with significant wight changes are referred to the dietitian who makes recommendations regarding diet and supplements to the resident's physician. The resident's family and physician will be notified of significant weight changes. The Dietitian Recommendation Process dated January 2022 documents: The Director of Nursing or designee will seek the physician's order changes in a timely manner. Responses should be obtained in 2-3 business days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 17 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide oxygen services by failing to change oxygen tubing and nasal cannula regularly to prevent possible contamination for one of one resident (R53) reviewed for oxygen services in the sample list of 35. Residents Affected - Few Findings include: The facility's Oxygen Concentrator Use policy with a revised date of 3/2008 documents, 8. Nasal cannula is to be changed at least weekly by licensed personnel, dated and initialed. 10. Water or pre-filled humidifier bottles are to be changed weekly, and when empty, dated and initialed. R53's Medication Administration Record (MAR) dated 4/1/22 through 4/30/22 documents diagnoses including Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Personal History of COVID-19 (Human Coronavirus) and Paroxysmal Atrial Fibrillation. R53's Treatment Administration Record (TAR) dated 4/1/22 through 4/30/22 documents an order dated 11/24/21 for oxygen via nasal cannula at 2L (liters) continuously for CHF (Congestive Heart Failure), except for short periods of time, every shift for Chronic Systolic CHF and Pulmonary Hypertension. This TAR also documents an order dated 4/8/20 to change O2 (oxygen) tubing/bottle/bag monthly, every night shift, starting on the 8th and ending on the 9th every month for protocols. This TAR documents the only time the oxygen tubing has been signed off as changed was on 4/8/22 and 4/9/22. R53's TAR dated 3/1/22 through 3/31/22 documents R53's oxygen tubing was changed on 3/8/22 and 3/9/22. On 4/26/22 at 3:19 PM, R53's oxygen tubing was dated 4/2/22 and there was no date on the humidification bottle. On 4/27/22 at 11:40 AM, V2 Director of Nursing stated V2 was not aware of why R53's oxygen tubing is only being changed once a month. V2 stated that it should be changed once a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 18 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to use alternative interventions prior to implementing bilateral siderails, and obtain a consent and physician order for the use of bilateral siderails for one (R56) of seven residents reviewed for accidents in the sample list of 35. Findings include: On 4/25/22 at 12:00 PM R56 was sitting in a wheelchair, had a seizure in the hallway, and staff assisted R56 into R56's room. On 4/25/22 at 2:50 PM R56 was lying in bed with bilateral siderails in the upright position on R56's bed. R56's Care Plan dated 9/1/20 documents R56 uses 1/4 side rail on the right side of the bed for positioning, R56 has seizures and Cerebral Palsy, and includes an intervention to obtain consent prior to initiating. R56's Physician's Order dated 9/17/19 documents to use 1/4 siderail on the right side of the bed for positioning. The Bed Rail Consent dated 9/17/19 signed by R56 documents 1/4 right siderail, and the alternative interventions attempted were no siderails. There is no documented consent for the use of bilateral siderails. R56's Bed Rail assessment dated [DATE] documents R56 uses 1/4 siderails on the left and right side of the bed. R56's Bed Rail assessment dated [DATE] documents R56 uses 1/4 right siderail, and does not assess for the use of 1/4 left siderail. These assessments documents the following as the alternative interventions attempted without positional enabler rail resident (R56) is unable to assist with bed mobility making (R56) reliant on staff for all repositioning needs. On 4/27/22 at 11:10 AM V7 Minimum Data Set Coordinator stated V7 completes the assessments for siderails, and the assessment should document interventions that were attempted prior to implementing the siderails. V7 confirmed R56's siderail assessments do not document what alternative interventions were attempted, and R56's consent is for the use of 1/4 right siderail. V7 stated R56 has Cerebral Palsy and uses the 1/4 right siderail for bed mobility, and the order is for 1/4 siderail. V7 stated R56 should not have both siderails up. The facility's Bed Rails policy dated 1/10/2018 documents Prior to the use of bed rails for a resident, the facility will document assessment of use, obtain physician order for use, and obtain consent from the responsible party or POAHC (Power of Attorney for Health Care.) This assessment and consent will be completed initially and reviewed quarterly, annually and with significant change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 19 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to review a resident's medication orders to prevent duplicate therapy and the potential for excess dosage for one (R2) of 17 residents reviewed for medications in the sample list of 35. Residents Affected - Few Findings include: The facility's undated Pharmaceutical Services Policy and Procedure Manual documents, Pharmacist Initial Review Procedure (Pharmacy) employs pharmacists that are responsible for the initial review of ALL orders that are dispensed by said pharmacy. When (Pharmacy) receives an order, an order-entry technician inputs the order into the pharmacy's operating software. The order is then reviewed for accuracy by a pharmacist. If the pharmacist identifies any issue with the order (including those of clinical significance), the facility for which the order is for, is contacted prior to the dispensing of the order by (Pharmacy). Any communication between facility and pharmacy is documented on the original order within (Pharmacy's) imaging software. This policy also documents, Consultant Pharmacist's Responsibilities. The following is a list of minimum expectations for (Pharmacy's) Consultant Pharmacists. Additional services may also be required, depending upon the facility or situation. 1. Perform reviews of each resident's drug therapy at least monthly, or more frequently where required, ensuring adequate monitoring and examining items including, but not limited to; Potentially clinically significant medication-related concerns, Drug interactions, Allergies, Side effects and adverse reactions, Labs associated with drug therapy, Appropriateness of dosages, Administration times, Consideration of more optimal alternatives, especially where drugs on Dr. Beer's list(Beers criteria medication list-reference) are involved and where specific drug therapy issues are outlined in the State Operations Manual, Documented diagnosis for each medication, Prn use, Duplicate therapy and number of medications being used, Duration of therapy, Psychotropic drug use, associated monitoring, and necessary documentation. R2's Medication Administration Record (MAR) dated 4/1/22 through 4/30/22 documents orders for Acetaminophen Extra Strength tablet 500 mg (milligrams), give two tablets (1,000 mg) by mouth twice a day for hip pain, maximum dose 4 grams in 24 hours with a start date of 3/3/21. This MAR documents an order for Acetaminophen tablet 325 mg, give 650 mg as needed every four hours for pain, not to exceed 4 grams in 24 hours including scheduled doses with a start date of 6/25/21. This MAR also documents an order for Acetaminophen 500 mg, give 1,000 mg every 12 hours as needed for pain due to tooth extraction, maximum dose 4 grams in 24 hours with a start date of 3/15/22. This MAR also documents an order for Tylenol 8 hours arthritis pain tablet Extended Release 650 mg, give 650 mg by mouth every 8 hours for back pain. Do not exceed 4 grams of Tylenol in 24 hours with a start date of 1/3/22. This is the only as needed Tylenol/Acetaminophen that was given in April, on 4/24/22 at 3:42 AM for a pain rating of 5/10. The above prescribed Tylenol/Acetaminophen has the potential to exceed the maximum daily dose of 4 grams. The potential total dosage in 24 hours adds up to 9,850 mg. On 4/27/22 at 11:40 AM, V2 Director of Nursing stated that the pharmacy completes monthly reviews and is usually good about making recommendations to reduce medications. V2 confirmed there is no pharmacy recommendation to reduce or stop any of the Acetaminophen/Tylenol prescribed to R2. V2 stated that since these Acetaminophen/Tylenol orders are separate the computer system would not recognize when multiple PRN (as needed) doses would be given. V2 confirmed with the multiple order of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 20 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0757 Acetaminophen/Tylenol there is a potential to exceed 4 grams per day. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 21 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document nonpharmacological interventions or identify and track resident specific behaviors for two residents (R11, R35) on psychotropic medications of five residents reviewed for psychotropic medications in a sample list of 35. Findings Include: 1. R11's progress notes dated 4/27/22 includes the following diagnoses: Alzheimer's Disease with Behavioral Disturbance, Major Depression, and Generalized Anxiety Disorder. R11's Physician's Orders dated 4/27/22 documents the following active Physician's Orders: Sertraline Tablet (anti depressant) 125 milligrams Give 1 tablet by mouth daily. Seroquel Tablet 25 milligrams (antipsychotic) Give 1 tablet by mouth at bed time. R11's Psychoactive Medication assessment dated [DATE] does not indicate nonpharmacological interventions attempted and does not identify specific targeted behaviors to support the need for psychotropic medication. There is no documentation to support any specific behaviors are being tracked by the facility. 2. R35's progress notes dated 4/27/22 includes the following diagnoses: Dementia with behavioral disturbance, Delirium, Other Signs and Symptoms Involving Emotional State. R35's Physician's Orders dated 4/27/22 documents the following active Physician's Orders: Seroquel Tablet (antipsychotic) 25 milligrams (mg.) Give 12.5 mg by mouth daily Zoloft Tablet (Antidperessant)25 milligrams Give 25 mg by mouth daily R35's Psychoactive Medication assessments dated 11/29/21, 1/3/22, 2/28/22, and 3/7/22 do not indicate nonpharmacological interventions attempted and do not identify specific targeted behaviors to support the need for psychotropic medication. There is no documentation to support any specific behaviors are being tracked by the facility. On 2/27/22 at 3:00PM V2, Director of Nursing stated We have no more documentation to support we attempted nonpharmacological interventions or are tracking specific behaviors for psychotropic medication for (R11 and R35). The facility's policy Psychotropic Medication dated 11/28/17 states These Medications (Psychotropics) are to be given to treat a specific condition medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 22 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to administer medications according to manufacturer's recommendations for two (R39, R53) of six residents reviewed for medication administration in the sample list of 35. There were 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.54%. Residents Affected - Few Findings include: 1.) R39's April 2022 Medication Administration Record (MAR) documents Carvedilol 6.25 mg (milligrams) take one tablet twice daily by mouth scheduled at 8:00 AM and 4:00 PM. On 4/25/22 at 3:36 PM V3 Licensed Practical Nurse (LPN) prepared, crushed, and administered R39's medications that included Carvedilol 6.25 mg one tablet. The Carvedilol medication card contained a label to take with food. R39's medications were given in a spoonful of applesause. 2.) R53's April 2022 MAR documents Carvedilol 25 mg take one tablet twice daily by mouth at 8:00 AM and 4:00 PM, and Symbicort aerosol 160-4.5 mcg (micrograms)/actuation give two puffs twice daily at 5:30 AM and 4:00 PM. On 4/25/22 at 3:55 PM V3 prepared and administered R53's medications which included Carvedilol 25 mg one tablet and Symbicort. The Carvedilol medication card contained a label that said take with food. R53 was not eating at the time the medication was given. The Symbicort inhaler contained a label that said shake well and rinse mouth after use. V3 did not instruct R53 to rinse R53's mouth with water after administering the Symbicort inhaler. On 4/25/22 at 3:28 PM V3 stated the facility starts serving supper at 5:00 PM. On 4/26/22 at 1:20 PM V16 Pharmacist stated: Carvedilol is absorbed better if taken with food. You should rinse the mouth after administering Symbicort inhaler It is a steroid and can cause thrush if the mouth is not rinsed after use. The Carvedilol manufacturer's instructions dated December 2008 documents Carvedilol is indicated for chronic heart failure, left ventricular dysfunction after a myocardial infarction, and hypertension. These instructions include Coreg (Carvedilol) should be taken with food to slow the rate of absorption and reduce the incidence of orthostatic effects. The Symbicort manufacturer's instructions dated January 2017 documents you should rinse the mouth with water without swallowing after administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 23 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm Based on observation, interview, and record review the facility failed to administer seizure 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 seizure that resulted in a fall with an elbow laceration that required sutures. Residents Affected - Few 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 seizure: 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. On 4/25/22 at 2:50 PM R56 stated R56 has a history of falling out of R56's wheelchair due to seizures, resulting in R56 being treated at the hospital. R56 was asked what the facility has done to keep R56 safe from injury during the seizures. R56 stated I'm just on heavy medications. R56's Care Plan dated 9/1/20 documents R56 has a seizure disorder and includes an intervention to administer seizure medications as ordered. R56's August 2021 Order Summary Report documents an order initiated on 1/20/21 to administer Keppra (seizure medication) 750 mg (milligrams) one tablet twice daily for a diagnosis of epileptic seizures. R56's August 2021 Medication Administration Record (MAR) does not document that R56's Keppra was administered on 8/8 and 8/9/22, and documents to refer to the progress notes. R56's Progress Notes document the following: On 8/8/21 at 8:17 AM R56's Keppra was on order. On 8/8/21 at 7:09 PM R56's Keppra entry documents Medication ordered; awaiting pharmacy. On 8/9/21 at 8:33 AM R56's Keppra was unavailable. On 8/9/21 at 9:20 PM R56's Keppra entry documents awaiting pharmacy. There is no documentation of any follow up with the pharmacy or that V15 Physician was notified of R56's missed doses of Keppra. R56's nurses notes document: On 8/10/21 at 6:20 AM R56 was in R56's wheelchair, fell to the floor, and had a seizure. R56 seized for 45 seconds to 1 minute. R56 had blood noted to both nostrils, an abrasion to the knee, and a 1 inch skin tear to the left elbow. R56 was sent to the emergency room and received two sutures to the left elbow. On 8/12/21 the IDT reviewed R56's fall and post fall interventions were to try and keep R56 safe and prevent injuries during seizures. R56's Hospital Summary dated 8/10/21 documents R56's Encounter Diagnoses were seizure and left elbow laceration, and to remove R56's left elbow sutures in 10 days. On 4/25/22 at 1:26 PM V4 Registered Nurse (RN) stated: R56 has a history of seizures. We monitor R56's Keppra levels and adjust R56's seizure medications. We count on the medication to keep R56 safe. On 4/27/22 at 11:50 AM V4 stated: V4 was working when R56 fell in August 2021. R56 had a seizure and fell forward out of R56's wheelchair onto the floor. R56 was bleeding from the nose and had skinned up R56's elbow. R56 was sent to the hospital and received two stitches to the left elbow. We were out of R56's Keppra. 8/9/22 was a Sunday, and we don't receive pharmacy deliveries on Sunday. We were waiting for pharmacy to deliver the medication. If a medication is unavailable we should notify the physician and document in the progress notes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 24 of 25 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 145470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Health-Hoopeston 423 North Dixie Highway Hoopeston, IL 60942 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)

F 0760 Level of Harm - Actual harm Residents Affected - Few On 4/27/22 at 12:00 PM V2 Director of Nursing stated V2 was not aware that R56 missed doses of Keppra in August 2021, and there was no medication error report completed. V2 stated we are to notify pharmacy and have the backup pharmacy deliver medications when they are unavailable. V2 stated the physician should be notified if the medication is not obtained and doses are missed. V2 stated Keppra is not in our convenience box of medications. V2 confirmed R56's nursing notes document Keppra was not available and was awaiting pharmacy deliver on 8/8 and 8/9/21, and there is no documentation that V15 Physician was notified of the missed doses. On 4/27/22 at 12:23 PM V16 Pharmacist stated: The half life of Keppra is 6-8 hours for instant release. R56 is on instant release Keppra. If Keppra doses are missed for 48 hours, V16 would be concerned about the patient having seizures and putting the patient at risk. The facility notified the pharmacy on 8/5/21 to request a refill of the Keppra. We told the facility that we still had R56 discharged to the hospital in our system and would need updated orders in order to refill the medication. We did not receive R56's orders until 8/9/21. The last fill of the Keppra was on 6/30/22, so that would have put R56 out of the medication roughly around 7/30/21. Usually the facility would let us know when they are out of a medication so that we can notify the backup pharmacy to have the medication delivered. V16 did not see any other documentation of communication from the facility regarding R56's Keppra during 8/5-8/9/21. On 4/27/22 at 1:51 PM V15 Physician stated: V15 was unsure if the facility had notified V15 of R56's missed doses of Keppra in August 2021. The facility should have had the backup pharmacy send the medication. The missed doses would be contributory to R56's seizure. Seizures can result in a fall, and depending on the type of seizure and if it affects the brain stem could result in death. V15 was unsure of the type of seizures that R56 has. The facility's Medication Administration policy dated 1/11/2010 documents: It is the policy of this facility to accurately administer medication following physician's orders. Missed doses of medications may occur, and the facility will contact the back up pharmacy or resident family for provision to the facility. Medication errors should be reported to the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145470 If continuation sheet Page 25 of 25