F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure allegations of verbal abuse were reported
immediately to the Administrator of the facility and in a timely manner to the State Agency for 1 of 3
residents (R2) reviewed for verbal abuse in a sample of 5.
Findings Include:
R2's Face Sheet, original admission date of 11/21/22, documented R2 has diagnoses of but not limited to
cerebral infarction, type II diabetes mellitus, major depressive disorder, and hypertension (HTN).
R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact, with a Brief Interview for
Mental Status (BIMS) of 13 out of 15, and requires some assistance with her activities of daily living
(ADLs).
On 06/24/25 at 9:25 AM, R2 said V4, Social Service Director (SSD), yelled at her and she didn't want to
talk about it. She said she didn't report it to anyone because what was the use in telling, it wouldn't have
accomplished anything, no one would have done anything, they never do.
On 06/24/25 at 9:10 AM, V6, Certified Nursing Assistant (CNA), said, On Wednesday (06/18/25) of last
week, (R2) was asking (V4) about going to the assisted living facility, and (V4) started yelling at (R2) and
was going through (R2's) drawers and slamming the drawers after going through them. V6 said when she
was done talking with R2, V4 even slammed R2's door when she walked out of R2's room. V6 said she
didn't report the incident to anyone because there is no one to report it to.
On 06/24/25 at 9:15 AM, V7, CNA, said she has heard and seen V4 yelling at R2. She said she was
standing out in the hallway, and she saw V4 going through R2's drawers, and when she was done going
through them, she slammed the drawer shut. V7 said she was yelling at R2 something about she (V4) just
couldn't make the assisted living take her. She said she didn't report it to anyone because nothing would
happen if she did report it.
On 06/24/25 at 9:45 AM, V8, CNA, said she was here at the facility last week when the incident with V4 and
R2 happened. She said she was standing out in the hallway and V4 was in the room yelling at R2. She said
she doesn't remember specifically what V4 was saying to R2, but she was yelling at R2. She said she also
saw V4 slam shut the dresser drawer, she was tossing things around and slammed the door when she left
the room. V8 said she didn't report it because it doesn't do any good, nothing matters to management, and
there is no one higher to go to.
(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
06/26/2025
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 06/25/25 at 1:40 PM, V1, Administrator, said he would expect to be notified immediately if there is an
allegation of abuse made. He said they have had multiple in-services since he started here at this facility,
and he has made it clear they are to notify him directly with any abuse allegation. He said he always uses
this scenario if there are three staff members standing at the nurse's station and they have a resident say
someone was mean to them, yelling at them, or rough with them, then he would expect three phone calls.
He said he tells them not to have the mentality of 'well I reported it to the nurse, or the other nurse will
report it', they should be reporting it.
On 06/24/25 at 2:00 PM, R2's Electronic Medical Record (EMR) was reviewed and there was no
documentation regarding the alleged verbal abuse that happened on 06/18/25.
R2's Illinois Department of Public Health (IDPH) investigation was reviewed and documented the following:
Initial Report- June 24th, 2025: On 6/24/25 at approximately 11am, it was reported by an IDPH Surveyor
that an allegation of verbal abuse was made by resident R2 regarding V4 (SSD). The investigation has
been initiated, and V4 (SSD) has been suspended pending the outcome of the investigation. MD (Medical
Doctor) and the local Police Department (Reference #), Ombudsman, and Responsible party are being
notified.The final report to follow once the investigation is complete.
The facility's Abuse, Prevention, and Prohibition Policy, date approved: 03/2025 documented, Abuse
Prohibition Program The facility's abuse prohibition program includes the following sever components:
Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response: The
facility Administrator will be designated as the facility Abuse Coordinator and will be responsible for
overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation. It also
documented Investigation: Resident abuse must be reported immediately to the Administrator. The facility
Administrator will ensure a thorough investigation of alleged violations of individual rights and document
appropriate action. It further documented Initiate investigation including initial reporting to all required
agencies.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145500
If continuation sheet
Page 2 of 2
