Inspection·May 12, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: R38's Physician Order Sheet (POS) dated 5/11/23, documents Aspirin Tablet Delayed Release 81 milligram give one tablet by mouth in the morning, Calcium 600+D Tablet 600-400 milligram-unit (Calcium Carbonate -Vitamin D) give one tablet by mouth in the morning, Cholecalciferol Tablet 50 micrograms (2000 UT) give one tablet by mouth in the morning, Cranberry Tablet 450 milligrams give one tablet by mouth in the morning for prevention of urinary tract infection, Docusate Sodium Oral Tablet 100 milligrams give one tablet by mouth two times a day, Gemfibrozil Tablet 600 milligrams give one tablet by mouth two times a day, Losartan Potassium Tablet 100 milligrams give one tablet by mouth in the morning, Memantine HCI five milligrams one tablet by mouth two times a day related to Unspecified Dementia, Multivitamin Tablet give one tablet by mouth in the morning, Seroquel Oral Tablet 50 milligrams give 50 milligrams by mouth in the [NAME] related to Unspecified Dementia, Unspecified Severity, with Agitation, and Sertraline HCI Oral Tablet 100 milligrams give 150 milligrams by mouth in the morning related to Major Depressive Disorder, Recurrent. R38's Physician Order Sheet (POS) dated May 2023, documents R38's diagnoses as Major Depressive Disorder, Recurrent, Unspecified, Mood Disorder Due to Known Physiological Condition, Unspecified, Anxiety Disorder, Unspecified, and Unspecified Dementia, Unspecified Severity, with Agitation. R38's Care Plan dated 5/4/23, documents R38 uses antipsychotic medications related to behavior management- administer medications as ordered. This Care Plan also documents R38 uses an antidepressant related to Depression. R38's Medication Administration Record (MAR) dated May 2023, documents R38 refused morning medications on 5/7/23, 5/9/23, and 5/10/23. R38's Nursing Progress Notes dated 5/7/23 at 9:42 AM, documents resident (R38) refusing all medications this morning. There is no documentation of R38's physician being notified of R38 refusing R38's medication. R38's Nursing Progress Notes dated 5/9/23 at 9:49 AM, documents several attempts to see if resident (R38) would take her (R38) medications resident (R38) ended up not taking her (R38) meds (medications). There is no documentation at this same time of R38's physician being notified of R38 refusing R38's medications. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145470 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 05/12/2023 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)