Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Health-hoopeston during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, who was wheelchair-bound and dependent on staff for transfers, had a care plan intervention requiring staff to transfer him to a recliner when he leaned in his wheelchair or appeared tired. Staff observed the resident dozing in his wheelchair in the dining room, where he often removed his laptop cushion, but did not transfer him as directed. Later, staff responded to a sounding chair alarm and found him on the floor beside his wheelchair. Subsequent hospital evaluation revealed acute fractures of the left ulna and left femoral neck related to this fall, and nursing leadership confirmed that the care-planned fall intervention to move him to a recliner when sleepy had not been implemented.
The facility failed to protect residents from physical abuse when two severely cognitively impaired, wheelchair-dependent residents with documented behavioral symptoms began arguing in a hallway and one struck the other on the arm. Both residents required substantial to maximum assistance with ADLs and had multiple psychiatric and medical diagnoses. A witness observed the altercation, and the Administrator confirmed the incident, demonstrating a failure to uphold the facility’s abuse prohibition policy and to prevent resident-to-resident physical abuse.
A resident with dementia, psychosis, severe cognitive impairment, and recurrent behavioral symptoms hit another resident on the arm during an argument in a hallway, an event witnessed by a third resident. Despite this incident of physical abuse and the resident’s documented behavioral history and high ADL needs, the care plan did not include any problem or interventions addressing the abuse or the hitting incident, and was not revised in a timely manner as required by facility policy.
Two cognitively intact residents reported receiving towels and washcloths with frayed edges and holes, and observations confirmed the presence of worn linens in the clean linen cart. The Housekeeping Supervisor acknowledged that staff were not consistently discarding damaged linens, resulting in residents being provided with substandard items.
The facility failed to report an injury of unknown origin and changes in medication orders for two residents. A resident with moderate cognitive impairment had a medication change that was not communicated to their family. Another resident with severe cognitive impairment had a bruise that was not reported to their family or physician until days later. The facility's policies on reporting changes and injuries were not followed.
The facility failed to report abuse allegations and injuries of unknown origin for three residents. One resident's bruise was reported late, another's family reported a nurse's alleged yelling, and a third resident's claim of being hit was not documented. These incidents were not reported to the state agency as required, indicating a breakdown in reporting procedures.
The facility failed to investigate abuse allegations for three residents, including one with severe cognitive impairment who reported being squeezed by staff, another whose family reported a nurse yelling, and a third who claimed to be hit by another resident. These incidents were not documented or investigated, and no staff were placed on leave.
The facility failed to implement fall interventions, document falls, and perform safe transfers for three residents. A resident with cognitive impairment fell while being assisted into a recliner, and the fall was not documented in the medical record. Another resident, requiring substantial assistance, experienced multiple falls due to improper transfer procedures and lack of thorough investigation. A third resident, at risk for falls, had several unwitnessed falls, with missing documentation and interventions not being followed.
The facility failed to label refrigerated chopped onions and tomatoes with dates and did not monitor cooking temperatures, risking food safety for all 72 residents. The Dietary Manager admitted these items would have been served without the surveyor's intervention, and temperature logs showed missing records for several meals over multiple weeks.
The facility failed to document orders, consents, or assessments for restraints used on four residents. A body pillow was used as a restraint for two residents without proper documentation. Another resident used a breakaway lap cushion without an initial assessment, and a fourth resident used a soft lap cushion without documented consent. The facility's staff acknowledged these deficiencies.
The facility failed to administer medications correctly for three residents, resulting in a 16% medication error rate. A resident received an incorrect dose of Metamucil, while two others were given insulin without following proper timing and priming procedures, contrary to manufacturer's instructions.
The facility failed to properly label and store medications for eight residents, leading to deficiencies in medication management. Insulin pens and eye drops were not labeled with full names or opened dates, and some were used past their beyond use dates. The DON confirmed that medications should be labeled correctly and expired or discontinued medications should be returned to the pharmacy.
A facility failed to conduct a Level II PASRR for a resident with PTSD, despite the diagnosis being recorded. The resident was cognitively intact, and the facility's administrator was unaware of the requirement to obtain a Level II PASRR when a serious mental illness is identified. The facility lacked a specific policy for obtaining a Level II PASRR.
The facility did not provide necessary shaving assistance to two residents who are dependent on staff for personal hygiene. One resident, unable to use his hands, was observed with significant beard growth and expressed a desire to be clean-shaven. Another resident, cognitively intact and requiring shaving assistance, was also unshaven over several days. Both residents expressed dissatisfaction with the lack of daily shaving, and a nurse confirmed the expectation for residents to be shaved during morning care.
A resident with multiple diagnoses, including Dementia and knee contractures, was improperly transferred using a sit-to-stand mechanical lift. The CNA and students did not position the resident's knees against the knee pad or use the leg strap, causing the resident to slide in the sling with elbows raised. The facility's Director of Nursing confirmed the correct procedure was not followed.
A facility failed to provide trauma-informed care for a resident with PTSD, as their care plan lacked documentation of triggers and interventions. The resident preferred a dark room to stay calm, but the Assistant DON was unaware of the PTSD's cause or triggers. The facility had no Social Service Director since January, and the resident's PTSD was not addressed with a consultant.
A registered nurse failed to perform hand hygiene before and after administering insulin and eye drops to two residents, contrary to the facility's Medication Administration policy. The nurse confirmed the omission, and the Director of Nursing stated that hand hygiene should occur between each resident during medication pass.
Failure to Implement Care-Plan Fall Interventions Resulting in Resident Fractures
Penalty
Summary
The facility failed to implement fall interventions as outlined in its Fall Assessment and Management Policy for a resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, dementia with agitation, anxiety, and chronic pain. The resident’s care plan identified a risk for falls related to confusion and poor safety awareness and included an intervention, added on 2/11/25, directing staff to assist the resident in transferring into a recliner when he was leaning in his wheelchair or appeared tired. On 2/26/26, nursing notes documented that the resident was found on the dining room floor lying on his left side next to his wheelchair, with his laptop cushion removed. The RN noted that the resident often fell asleep in his wheelchair and that, without the laptop cushion, he could easily fall forward due to leaning. An interdisciplinary team note dated 3/6/26 documented that staff heard the resident’s chair alarm sound while he was sitting in the dining room, and upon responding, found him lying on his left side on the floor next to his wheelchair. The resident was known to be wheelchair-bound and dependent on staff for all transfers. During a subsequent hospital admission for hypoxia and low-grade fever, the resident complained of left wrist and hip pain, and imaging revealed an acute nondisplaced distal shaft fracture of the left ulna and an acute left femoral neck fracture related to the earlier fall at the facility. In interviews, the RN and the Assistant Director of Nursing confirmed that the resident often fell asleep in his wheelchair and that staff should have transferred him to his recliner when he appeared sleepy, consistent with his care plan intervention, but this was not done prior to the fall.
Failure to Prevent Resident-to-Resident Physical Abuse During Hallway Argument
Penalty
Summary
The facility failed to protect residents from physical abuse when one resident struck another during an argument. The facility’s Abuse Prohibition policy, revised on 8/25/25, affirms that all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. Despite this policy, an incident occurred in which two residents who were sitting in the hallway talking began to argue, and one resident hit the other on the arm. A witness reported seeing the resident raise a hand and smack the other resident on the arm after becoming upset during the disagreement. The residents involved both had significant cognitive and functional impairments documented in their medical records and MDS assessments. One resident had diagnoses including fibromyalgia, dementia without behavioral disturbances, and psychosis, was severely cognitively impaired, exhibited physical/verbal behavioral symptoms one to three times a week, used a wheelchair for mobility, and required substantial to maximum assistance with all ADLs. The other resident had diagnoses including lumbar spinal stenosis without neurogenic claudication and delusional disorders, was also severely cognitively impaired, exhibited physical/verbal behavioral symptoms one to three times a week, used a wheelchair, and required substantial to maximum assistance with ADLs. The incident in which one resident hit the other on the arm, as confirmed by a witness and the Administrator, represents a failure to uphold the facility’s abuse prohibition policy and to protect residents from physical abuse by another resident.
Failure to Revise Care Plan After Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan following an incident of resident-to-resident physical abuse. A facility-reported incident investigation documents that one resident hit another resident on the arm in the hallway while they were talking and arguing, and a third resident witnessed the event. The resident who struck the other has medical diagnoses including fibromyalgia, dementia without behavioral disturbances, and psychosis. Their MDS shows severe cognitive impairment, physical/verbal behavioral symptoms occurring one to three times per week, wheelchair use for mobility, and a need for substantial to maximum assistance with all ADLs. Despite this incident of physical abuse, the resident’s care plan, last reviewed on 1/27/26, did not include any problems or interventions addressing the abuse or the hitting of the other resident. There was no documentation on the care plan related to the incident that occurred on 12/6/25. During interview and care plan review, the RN ADON confirmed that there was no information about the incident on the care plan and acknowledged that issues arising from incidents are to be addressed on the care plan as soon as possible. The Administrator also stated awareness that the care plan had not been revised until 2/4/26, although facility policy requires revising care plans as soon as possible after an event.
Failure to Provide Clean, Intact Linens for Residents
Penalty
Summary
The facility failed to maintain a homelike environment by not ensuring that linens provided to residents were in good condition. Two cognitively intact residents reported receiving towels and washcloths that were worn, with frayed edges and holes. One resident displayed a towel with frayed edges and two washcloths with fraying on every side, expressing confusion as to why staff continued to provide such items instead of replacing them with linens in good shape. Another resident showed a washcloth with a large hole and frayed edges, noting that he had seen worse and expected better quality in the facility. Observations confirmed the presence of frayed washcloths in the clean linen cart. The Housekeeping Supervisor stated that laundry is outsourced and that staff are responsible for discarding worn linens, but acknowledged that this was not being consistently done.
Failure to Report Injury and Medication Changes
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the physician and resident representative, as well as changes in medication orders to the resident representative for two residents. One resident, identified as R1, had a moderate cognitive impairment and experienced a change in medication when Plavix was discontinued. The Assistant Director of Nursing (ADON) attempted to contact the resident's family but failed to document the notification. The facility's policy requires that resident representatives be informed of changes in treatment, which was not adhered to in this case. Another resident, R2, with severe cognitive impairment, had a bruise that was not reported to the family or physician until three days after it was discovered. The bruise was noted to be aging, indicating it was not fresh, and was considered an injury of unknown origin. The Director of Nursing confirmed that the bruise should have been reported immediately. The Licensed Practical Nurse (LPN) involved did not report the bruise to anyone and admitted to not having training on identifying and reporting such injuries. The facility's policy mandates that injuries of unknown origin be reported to the resident's physician and family, which was not followed in this instance.
Failure to Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin in a timely manner for three residents. The facility's policy requires immediate reporting of such incidents to the administrator and the state surveying agency. However, the facility's abuse tracking log did not document any allegations involving the residents in question. For one resident, a bruise was discovered but not reported to management or the state agency until four days later, despite the facility's policy requiring immediate reporting. Another resident's family reported an incident where a nurse allegedly yelled at the resident while changing the television channel. Although the family member later apologized, the incident was not reported to the state surveying agency as required. The facility's administrator was unaware of the allegation, indicating a breakdown in communication and reporting procedures. A third resident reported being hit by another resident, but this was not documented in the facility's abuse log or reported to the state surveying agency. The facility's administrator confirmed that this incident should have been reported, highlighting a failure to adhere to the facility's abuse reporting policy. These deficiencies demonstrate a lack of compliance with established procedures for reporting abuse and injuries of unknown origin, potentially compromising resident safety.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse and implement protective measures for three residents. One resident, who has severe cognitive impairment, frequently complained of being squeezed by unidentified staff during care. Despite these complaints being reported to management, the facility's abuse log did not document any allegations involving this resident, and no investigation was conducted. The Director of Nursing was aware of the accusations and had implemented a two-staff care protocol, but the Administrator was not informed of the specific allegations, and the accused staff member was not placed on leave. Another resident's family reported an incident where a nurse allegedly yelled at the resident while changing the television channel. The family member reported this to the Administrator and a corporate official, but the incident was not considered an abuse allegation by the Director of Nursing, who believed the issue was resolved after the family member apologized. Consequently, the incident was not investigated, and the nurse was not placed on leave. A third resident, also with severe cognitive impairment, reported being hit by another resident. A CNA reported this to the Administrator, but the Administrator stated that nothing had been reported, and the incident was not documented in the facility's abuse log. As a result, the allegation was not investigated, indicating a failure in the facility's abuse reporting and investigation processes.
Failure to Implement Fall Interventions and Document Falls
Penalty
Summary
The facility failed to implement fall interventions, document falls in medical records, perform safe transfers, and thoroughly investigate falls for three residents. Resident 1, who has moderate cognitive impairment and is dependent on staff for transfers, experienced a fall while being assisted into a recliner with a sit-to-stand lift. The fall was not documented in the resident's medical record, and the Assistant Director of Nursing confirmed that falls should be documented in a nursing note. Resident 2, with severe cognitive impairment and requiring substantial assistance for transfers, experienced multiple falls. One fall occurred when a CNA assisted the resident into a chair without using a gait belt or having a second staff member present, despite the resident's care plan requiring two staff for transfers. Another fall was unwitnessed, and the investigation lacked staff statements or interviews to determine when the resident was last observed or toileted. Resident 6, who has severe cognitive impairment and is at risk for falls, experienced several unwitnessed falls. The care plan included an intervention for a nonskid mat, but it was not present in the resident's wheelchair. The fall investigations did not include staff interviews or documentation of when the resident was last observed or provided toileting assistance. The Assistant Director of Nursing confirmed the lack of documentation and awareness of the nonskid mat intervention.
Food Safety Protocols Not Followed
Penalty
Summary
The facility failed to adhere to proper food labeling and temperature monitoring protocols, which are essential for ensuring food safety. During an inspection, it was observed that chopped onions and tomatoes were stored in the refrigerator without any date labels. The Dietary Manager acknowledged that these items should have been dated when they were chopped and stored, and admitted that they would have been served had the issue not been identified. This oversight in labeling could lead to the growth of bacteria, posing a risk to the health of all 72 residents in the facility. Additionally, the facility did not consistently monitor or document cooking temperatures, as evidenced by missing temperature records for several meals over multiple weeks. The Food Temperature Logs for various weeks showed no recorded temperatures for several meal services, indicating a lack of compliance with the facility's own procedures. The Dietary Manager confirmed that cooking times are supposed to be monitored to ensure thorough cooking, but this was not being done, further increasing the risk of foodborne illness among residents.
Improper Use of Restraints Without Documentation
Penalty
Summary
The facility failed to adhere to its Restraint Program Policy and Procedure, resulting in the use of restraints without proper orders, consents, or assessments for four residents. Resident R52, who is severely cognitively impaired, was observed with a body pillow used as a restraint without any documented order, consent, or assessment. The Assistant Director of Nursing confirmed that the body pillow could be considered a restraint and acknowledged the lack of necessary documentation. Similarly, Resident R219, who is confused and not interviewable, was found with a body pillow used to prevent them from getting out of bed. Staff confirmed the use of the pillow as a restraint, yet there was no consent, assessment, or order documented in the resident's medical record. The Assistant Director of Nursing acknowledged the improper use of the body pillow and the absence of required documentation. Resident R47, who is severely cognitively impaired, was using a breakaway lap cushion as a restraint without an initial assessment documented. The Director of Nursing admitted that the initial assessment was missed. Additionally, Resident R55, diagnosed with dementia and other conditions, was using a soft lap cushion as a restraint without documented consent. The Director of Nursing confirmed the lack of consent documentation for the restraint change from a hook and loop closure belt to a soft lap cushion.
Medication Administration Errors and Non-Compliance with Manufacturer Instructions
Penalty
Summary
The facility failed to administer medications as ordered and in accordance with manufacturer's instructions for three residents, resulting in a medication error rate of 16%. For one resident, a registered nurse administered an incorrect dose of Metamucil, providing only 1/2 teaspoon instead of the prescribed 12 grams, as confirmed by the nurse and the medication label. Another resident was administered Humalog insulin without priming the pen, and the insulin was given over 30 minutes before the resident received their meal, contrary to the manufacturer's instructions that it should be administered within 15 minutes before a meal. Additionally, a third resident received Admelog insulin 40 minutes before their meal, which is outside the recommended administration window of within 15 minutes before a meal. The facility's medication administration policy requires following physician's orders and comparing the medication label with the MAR, which was not adhered to in these cases. The failure to prime the insulin pen and the timing of insulin administration could lead to incorrect dosing, as noted in the manufacturer's instructions.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for eight residents, leading to deficiencies in medication management. During an inspection, it was observed that several insulin pens and eye drops were not labeled with the residents' full names or opened dates, and some medications were used past their beyond use dates. For instance, a Lispro insulin pen for one resident was labeled with an opened date that exceeded the beyond use date, while another resident's Basaglar insulin pen lacked an opened date. Additionally, a Novolog insulin pen was labeled only with a resident's nickname and no opened date. The Registered Nurse verified these labeling issues and acknowledged the incorrect assumption about the insulin's usability period. Further inspection revealed that an eye drop bottle was labeled with an opened date that surpassed the discard date, and another resident's eye drops were still in the cart despite the resident no longer residing in the facility. Insulin pens for two residents were only labeled with first names, and another resident's insulin pen was not labeled with an opened date, even though the medication was discontinued. The Director of Nursing confirmed that medications should be labeled with full names and opened dates, and expired or discontinued medications should be returned to the pharmacy. The facility's pharmacy guide and policy manual also outlined these requirements, emphasizing the importance of adhering to beyond use dates and proper labeling to maintain medication efficacy and safety.
Failure to Obtain Level II PASRR for Resident with PTSD
Penalty
Summary
The facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with Post-traumatic Stress Disorder (PTSD). The resident, identified as R57, was found to have an active diagnosis of PTSD and was cognitively intact according to the Minimum Data Set (MDS) dated [DATE]. Despite this diagnosis being recorded on 6/30/23, there was no evidence in the medical record that a Level II PASRR screening was conducted. During an interview on 6/5/24, the facility's administrator, V1, admitted to being unaware of the requirement to obtain a Level II PASRR when a serious mental illness diagnosis is identified, if not indicated by the Level I PASRR. Additionally, it was confirmed that while the facility's Care Plan Procedure policy includes PASRR recommendations in the initial Care Plan, there is no specific policy regarding when to obtain a Level II PASRR.
Failure to Provide Shaving Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care, specifically shaving, for two dependent residents, R12 and R17, who require assistance with activities of daily living. R17, who is dependent for all activities of daily living, was observed with significant beard growth on multiple occasions, despite expressing a preference for being clean-shaven and an inability to use his hands. Similarly, R12, who is cognitively intact and requires assistance with shaving as per his care plan, was also observed with unshaven facial hair over several days. Both residents expressed dissatisfaction with not being shaved daily, and a Registered Nurse acknowledged the expectation for residents to be shaved during morning care.
Improper Use of Mechanical Lift During Resident Transfer
Penalty
Summary
The facility failed to perform a safe sit-to-stand mechanical lift transfer for a resident diagnosed with Dementia, Contracture of both knees, Muscle Weakness, Muscle Wasting, Abnormal Posture, Obesity, Anxiety, and Depression. During the transfer, the resident's knees were not positioned against the knee pad, and the leg strap was not used, causing the resident's elbows to raise towards the ceiling in a 'chicken wing' position. The resident's legs remained bent, and she began sliding down in the sling, indicating an improper transfer technique. The incident was observed by a Certified Nursing Assistant (CNA) and two CNA students, who did not follow the correct procedure as outlined in the mechanical lift's instruction manual. The Director of Nursing confirmed that competency training is conducted for staff on all mechanical lifts, and the resident's knees should be against the knee pad, with elbows at the resident's side. The Occupational Therapy Assistant assumed the resident could straighten her legs enough to be safe on the lift, but acknowledged that the resident's knees should be against the knee pad and arms should not be raised.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with Post-traumatic Stress Disorder (PTSD), as required by their policy. The policy mandates that residents who are trauma survivors receive culturally competent, trauma-informed care, with efforts to eliminate or mitigate triggers that could cause retraumatization. However, the facility did not identify potential triggers or implement resident-centered trauma-based interventions for the resident with PTSD. The resident's care plan, revised in April 2024, did not document the events leading to the PTSD or potential triggers, nor did it include any specific interventions for managing the PTSD. During an observation, the resident was found lying in a dark room, which she stated helped her stay calm. The Assistant Director of Nursing admitted to not knowing the cause of the resident's PTSD or what triggers it, and acknowledged that the PTSD was not addressed in the care plan. The facility had been without a Social Service Director since January, and the duties were shared among staff with the help of a consultant, but the resident's PTSD had not been addressed with the consultant. This lack of attention to the resident's PTSD needs represents a deficiency in the facility's care practices.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to adhere to its Medication Administration policy, which requires hand hygiene before and after medication administration. During an observation, a registered nurse did not perform hand hygiene before or after administering insulin to one resident and eye drops to another. The nurse applied gloves, administered Admelog insulin to a resident's abdomen, removed the gloves, and then proceeded to administer Timolol Maleate eye drops to another resident without performing hand hygiene in between. The nurse confirmed the omission of hand hygiene during the medication pass. The Director of Nursing stated that nurses are expected to perform hand hygiene or use hand sanitizer between each resident during medication administration. This expectation was not met in the observed instances, leading to a deficiency in infection prevention and control practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hoopeston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Iroquois Resident Home, The | 20.5 mi | ★★★★★ | 0 | 0 |
| Hawthorne Inn Of Danville | 20.6 mi | ★★★★★ | 2 | 0 |
| Country Health | 20.8 mi | ★★★★★ | 23 | 0 |
| Accolade Hc Of Paxton On Pells | 20.8 mi | ★★★★★ | 6 | 0 |
| Accolade Paxton Senior Living | 21.4 mi | ★★★★★ | 2 | 0 |
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