Hillsboro Rehab & Hcc

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 emergency contact after an injury was sustained for 1 (Resident R5) of 3 residents reviewed for notification. Findings include: Resident R5's Undated Face Sheet, documents V29 is her emergency contact. Resident R5's Quarterly Minimum Data Set (MDS), dated [DATE REDACTED], documents Resident R5 is alert. Resident R5's Health Status Note, dated 10/21/2025 at 10:50 AM, documents PT (Physical Therapy) staff informed RN (Registered Nurse) that patients left anterior lower extremity was swollen and bruised. NP was in house and was notified to take a look, patient had a silver dollar sized bruise on the anterior shin/ankle, with redness and edema spreading around the bruise. Patient stated that she has broken that same leg/foot 3x and there is some hardware in there from past surgeries. Patient said when

they were transferring/pivoting her feet gave out. NP assessed patient quickly and RN was given the order to send patient to the ER (Emergency Room) for imaging evaluation. Patient was sent to the ER at approx (approximately) 8:45am via EMS (Emergency Medical Services).On 10/31/2025 at 1:25 PM, V29, Resident R5's emergency contact, stated no facility staff notified her on the morning of 10/21/2025 when Resident R5 sustained an injury and was transferred to the emergency room. V29 stated Resident R5 called her and told her she got her left foot stuck in the wheelchair wheel and her left foot/lower leg was injured and she was sitting in the emergency room. V29 stated she was upset because no facility staff notified her Resident R5 was injured or that she was transferred to the emergency room, and if she would have been notified of the severity of the injury she would have met Resident R5 at the emergency room to be there for family support. The Facility's Significant Condition Change and Notification policy, dated 12/2024, documents purpose: to ensure that the resident's family and/or representative. A significant change in resident's physical status includes onset of swelling, skin discoloration and transfer of the resident from the facility. Procedure: when any of the above situations exists, the licensed nurse will contact the resident's representative. Calls will be made to the resident's representative until they are reached. A message may be left on an answering machine that does not give specifics but leaves a request for the facility to be called.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hillsboro Rehab & Hcc

1300 East Tremont Street Hillsboro, IL 62049

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 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

not sure what the facility's policy is on when those are implemented and how staffing would be managed.

Facility's abuse policy, with a revision date of 3/2025, states, This facility prohibits mistreatment, neglect, or abuse of residents. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone. The facility will educate all employees upon hire and at least annually of the definitions of the Abuse Prevention and Prohibition Policy including definitions pertaining to abuse and neglect. Annually, the Administrator will contact local law enforcement to review the requirements for reporting to law enforcement.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hillsboro Rehab & Hcc

1300 East Tremont Street Hillsboro, IL 62049

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

assistance of 2 staff members. No injuries noted. Denies pain. VS/ROM/Neuros WNL. VS/Neuros initiated.

Resident noted to continue attempt to self-transfer at times. Resident's bed move to station 2 & mattress was placed next to bed. ADON notified of fall & provider notified. Will attempt to call POA in AM.Resident R10's Care Plan addressed his risk for falls, but no progressive interventions added to care plan after the two falls on 9/26/2025 to prevent future falls until 10/3/2025 staff documented two new interventions to prevent falls: scoop mattress and low bed. On 10/31/2025 at 11:50 AM, V28, Care Plan Nurse, stated she doesn't understand why Resident R10's care plan when printed documents the scoop mattress and low bed fall interventions were initiated on 9/26/2025, but in Resident R10's Electronic Medical Record (EMR) documents those same fall interventions were created on 10/3/2025. V28 stated she's never seen this issue with the dates not matching before and wasn't sure what the issue is. V28 stated she didn't know what date the fall interventions were implemented on, either 9/26/2025 or 10/3/2025. On 10/31/2025 at 12:00 PM, V1, Administrator, observed Resident R10's care plan fall interventions dates didn't match and stated she will ask V5, Regional Nurse Consultant, why the fall intervention dates of created and initiated don't match. V1 stated she's never seen this documentation issue before. On 10/31/2025 at 12:11 PM, V5, Regional Nurse Consultant, stated she called the facility's corporate office and she stated no one including her understand or has ever observed this documentation issue in a resident's EMR care plan. V5 stated the created date and the initiated date always match, and she doesn't know what's going on with the computer system and didn't know when Resident R10's fall interventions of the scoop mattress or the low bed was implemented. On 10/31/2025 8:55 AM, Resident R10 was observed sitting up in wheelchair in hallway. V26, CNA, propelled Resident R10 to his room. V27,CNA, applied a gait belt around Resident R10's waist and V26 and V27 assisted Resident R10 to stand and pivoted him to sit on the side of his bed. V26 held Resident R10's top half and V27 picked up Resident R10's feet and assisted him to lay in bed. Resident R10 didn't respond to surveyor's questions regarding the fall. Resident R10 had a scoop mattress and he had a low bed. On 10/31/2025 at 2:00 PM, V5, Regional Nurse Consultant, stated the facility's physician's order policy only covers staff needing to administer medications per physician's orders and doesn't include following physician's order for transfer status and V5 stated the facility doesn't have a proper transfer status policy.

Event ID:

Facility ID:

If continuation sheet