Hillsboro Rehab: Fall Care Failures Caused Actual Harm - IL
The resident, identified in inspection records as R10, fell twice on September 26, 2025. His care plan already documented his risk for falls. Nobody added new interventions to prevent another fall that day. Nobody added them the next day, either.
According to inspection records, it wasn't until October 3, 2025, a full week after the two falls, that staff documented two new protective measures: a scoop mattress and a low bed. Seven days.
What inspectors found when they looked closer made the timeline harder to pin down, not easier.
When the Care Plan Nurse, identified as V28, pulled up R10's records on October 31, she ran into something she said she'd never seen before. The printed version of the care plan showed the scoop mattress and low bed interventions had been initiated on September 26, the same day as the falls. The electronic medical record showed those same interventions were created on October 3. Two dates. Same interventions. Same patient. No explanation.
"She doesn't understand why R10's care plan when printed documents the scoop mattress and low bed fall interventions were initiated on 9/26/2025, but in R10's Electronic Medical Record documents those same fall interventions were created on 10/3/2025," the inspection report states. V28 told inspectors she didn't know which date was accurate and couldn't say when the interventions were actually put in place.
The administrator, V1, looked at the same discrepancy twelve minutes later and said she'd ask the Regional Nurse Consultant why the dates didn't match. She said she'd never seen the issue before.
The Regional Nurse Consultant, V5, called corporate. Corporate didn't know either. V5 told inspectors that the created date and the initiated date always match in the system, that she'd never seen this before, and that she didn't know what was going on with the computer. She also told inspectors she couldn't say when the scoop mattress or the low bed had actually been put in R10's room.
Nobody knew. Not the nurse who manages care plans. Not the administrator. Not the regional consultant. Not corporate.
The result is a gap that matters: if the interventions weren't in place until October 3, R10 spent a week after two falls without the added protections his care plan eventually required. The inspection was cited at a level of actual harm.
Inspectors observed R10 on the morning of October 31. He was sitting in a wheelchair in the hallway. A CNA named V26 pushed him to his room, where another CNA, V27, applied a gait belt. The two staff members helped R10 stand, pivoted him to sit on the edge of his bed, then assisted him to lie down, with one holding his upper half and the other lifting his feet. He had a scoop mattress. He had a low bed. He didn't respond to the surveyor's questions about his fall.
Earlier nursing notes captured what those two days in late September looked like. R10 had attempted to transfer himself without waiting for staff, which the notes described as an ongoing behavior. After one of the falls, staff found him on the floor and needed two people to help him up. No injuries were noted. Vital signs and neurological checks were initiated. His bed was moved closer to the nursing station and a mattress was placed on the floor beside it. The notes say staff planned to call his power of attorney in the morning.
The inspection also surfaced a separate problem. V5, the Regional Nurse Consultant, told inspectors that the facility's physician order policy only covers medication administration. It does not cover following physician orders for transfer status. She stated the facility has no proper transfer status policy.
R10's care plan had documented his fall risk. The notes recorded his tendency to attempt self-transfers. The interventions, whenever they were actually put in place, were the right ones. What the facility cannot account for is the week in between, and now, under scrutiny, cannot even confirm with certainty that the week existed the way the records suggest it did.
The date discrepancy remains unresolved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillsboro Rehab & Hcc from 2025-11-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 23, 2026 · Our methodology
HILLSBORO REHAB & HCC in HILLSBORO, IL was cited for violations during a health inspection on November 4, 2025.
The resident, identified in inspection records as R10, fell twice on September 26, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.