Inspection·March 4, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Record Review the facility failed to ensure a resident was free from abuse, from a resident with a history of prior altercations, for 1 of 6 (R4) residents reviewed for abuse in the sample of 6. Findings include: 1. R4's Face sheet documents an admission date of 12/18/2024. Diagnosis include Unspecified Dementia with Agitation, Congestive Heart Failure, Respiratory Failure, and Malignant Neoplasm of Colon. R4's Minimum Data Set, MDS, documents R4 is severely cognitively impaired. R4 requires partial/moderate assist with transfers and mobility. R4's Care Plan, dated 2/19/2025, documents R4 has been identified as a vulnerable person related to cognitive deficit. R4 has the potential for aggression related to her cognitive deficit. Interventions include R4 at times will believe she recognizes residents as people from her past and will seek them out to confront them. Staff will provide redirection to other area of facility and offer activities of her choice. R4 will have 1:1 supervision with each resident-to-resident incident and sent to hospital for evaluation with 1:1 supervision for 24 hours after return. Staff educated completed regarding abuse and neglect. Trauma assessment will be completed with each incident involving another resident. R3's Face sheet documents an admission date of 11/27/2024. Diagnosis include Metabolic Encephalopathy, Dementia, Hypertension, and Altered Mental Status. R3's MDS, dated [DATE], documents R3 is moderately cognitively impaired. R3 is independent with mobility and transfers. R3's Care Plan, dated 2/19/2025, documents R3 has potential to become aggressive related to dementia diagnosis. R3 has been identified as a vulnerable person related to diagnosis of dementia. Interventions include 1:1 supervision will be completed until R3 is sent to hospital for evaluation, and for 24 hours upon returning from hospital. Nursing will work closely with long term care psychiatrist related to medication reviews to ensure her needs are met. PHQ 9 assessment will be completed with each incident involving another resident. Trauma assessment will be completed with each incident involving another resident. When R3 is noted to be agitated, pacing or attempting to argue with others; staff will provide redirecting by offering a snack, glass of iced tea, or encourage R3 to participate in an activity of her choice. Staff to continue to redirect until redirection is successful. (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 2 Event ID: 145500 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 145500 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 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)