Health inspection·June 26, 2025

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. Page 1 of 2 145500 145500 06/26/2025 Hillsboro Rehab & Hcc 1300 East Tremont Street Hillsboro, IL 62049

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. 145500 Page 2 of 2