Inspection·October 8, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few orders given.On [DATE] at 9:40 AM, V6, CNA, stated the air mattress hospice brought in for R2 was never put on his bed and she doesn't know why. V6 stated hospice picked the mattress up last week after R2 passed away.On [DATE] at 10:20 AM, V2, DON, stated she is a traveling DON, started at this facility approximately 3 weeks ago. Hospice ordered an overlay for R2. V2 stated, We decided those aren't safe, so we ordered an air mattress from hospice, and it didn't come until (R2) had already expired. V2 stated R2 had multiple pressure ulcers. V2 stated on [DATE], R2 had tiny areas on his coccyx, on the 22nd it appeared as a Kennedy ulcer and the Nurse Practitioner came and looked at it, and then diagnosed it as a Kennedy ulcer.On [DATE] at 10:25 AM, V10, RN (Registered Nurse), stated R2's pressure ulcers gradually got worse after he was re-admitted on [DATE]. V10 stated when R2 was re-admitted to the facility on [DATE], she completed R2's admission assessment including his skin assessment. V10 stated she observed an approximate nickel sized open area to R2's sacrum on [DATE]. V10 stated towards the end of R2's stay at the facility, he started developing more wounds. V10 stated R2's hospice company delivered an overlay for his mattress, but it didn't follow protocol, so it was never placed on his bed. V10 stated she is not sure who made the decision not to use the overlay. On [DATE] at 10:43 AM, V2, DON, was asked if the facility assessed, measured, and monitored R2's pressure ulcer on his sacrum between [DATE] when it was noted on his re-admission assessment as 1.1 cm in length x 1 cm depth until [DATE] when the next measurement of 2.36 cm length x 3.57 cm width x .2 cm depth. V2 replied, I can't tell you anything, unfortunately. We did have a wound care nurse, but she quit. Surveyor asked if a low air loss mattress/air overlay was ever implemented for R2, and V2 replied, not that I know of our mattresses are pressure reducing. Surveyor asked V2 if she was the DON referenced to in R2's progress note, dated [DATE] at 7 PM, that documented hospice nurse here to see resident. During care she asked CNA why low air loss mattress isn't on bed and the CNA said, because the DON doesn't like them. V2 replied, They were referring to me; I don't like them. Surveyor asked if the facility has any documentation regarding their requests for a different type of low air loss mattress for R2 from hospice and V2 replied, I don't know, you will have to ask (V10) RN. Surveyor asked V2 if the facility measures wounds/pressure ulcers weekly and V2 replied, I would have to look that up in the policy.R2's Skin Check form, dated [DATE], documented resident refused skin check. This form was documented by V12, LPN (Licensed Practical Nurse). On [DATE] at 2:56 PM, V12, LPN, stated she attempted to assess R2's skin on [DATE] and R2 refused by being combative. V12 stated she passed it on in report so the nurse on the next shift should have attempted to check R2's skin.R2's EMR (electronic medical record) does not document another skin assessment until [DATE]. On [DATE], R2's wound evaluation form documented stage 2 pressure ulcer on sacrum with measurements of 12.24 cm area, 2.36 cm length, 3.57 cm width, and 0.2 cm depth. R2's wound evaluation forms, dated [DATE], also documented R2 had a pressure ulcer of his right heel that was acquired in house with measurements of 4.76 cm area, 2.98 cm in length, and 1.93 cm in width, a pressure wound to his front right lateral lower leg that was acquired in house, age unknown with measurements of 2.74 cm area, 1.6 cm in length, and 2.22 cm in width. R2's Wound Evaluation forms, dated [DATE], documented R2 developed a new stage 1 pressure ulcer on his left scapula measuring 407.21 cm in area, 28.68 cm in length, and 17.04 cm in width. R2 also developed a stage 1 pressure ulcer to his right lower back measuring 39.66 cm area, 13.12 cm in length, and 3.79 cm in width. A skin tear to his right lower back measuring 55.52 cm in area, 10.5 cm in length, by 10.22 cm in width. R2 developed a blister to his front right trochanter (hip) measuring 21.44 cm area, 3.9 cm in length, and 7.91 cm in width. R2's wound evaluation form, dated [DATE], also documented the pressure ulcer to his sacrum was unstageable (slough and/or eschar) with dimensions of area 130.23 cm, length 12.33 cm, and width of 14.86 cm with a progress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145500 If continuation sheet Page 2 of 5 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 10/08/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few note documenting area x 3 to sacrum evaluated this week. Wound bed is pink in color. Small amount of serosanguinous drainage noted with no odor present. R2's wound evaluation form, dated [DATE], documented R2's pressure injury to his front right lateral lower leg measured area at 35.62 cm, 15.62 cm in length, and 2.98 cm in width. The facility's wound line list, dated [DATE], documented 5 new pressure ulcers that were not present on R2's re-admission assessment dated [DATE]. On [DATE] at 8:49 AM, V15, R2's daughter and POA (Power of Attorney), stated she called the DON on [DATE] and informed her that her dad (R2) did not have a dressing on his sacral wound when she visited. V15 stated the DON (V2) replied it didn't need a dressing. V15 stated her dad's wound was a stage 2 at this time and it did need a dressing. Surveyor asked V15 if she has medical experience and V15 replied, Yes, I am an LPN with 25 years of experience in long term care. V15 stated hospice ordered an air mattress and facility staff threw it in the closet and never used it. V15 stated she was at the facility the weekend of [DATE] and her dad's sacral wound was bigger, open, and bleeding onto his sheets. V15 stated the mattress overlay was still in his closet and she spoke to R2's hospice nurse about her concerns with his skin breakdown and lack of interventions. V15 stated the hospice nurse stated she ordered a full bed, and the facility refused it. V15 stated she visited her dad on [DATE], and shortly after, she left her niece, who was still at the facility, called her along with the hospice nurse because the hospice nurse wanted to make sure she knew her dad had developed more pressure ulcers, and the mattress overlay was still in his closet. On [DATE] at 1:48 PM, V11, Nurse Practitioner, was asked if she would have expected the facility to implement an alternating pressure mattress for R2, and V11 stated, I believe they were getting one from hospice. Surveyor then asked if she would have expected the facility to implement an alternating pressure mattress/overlay as care planned by R2's hospice program on [DATE] when R2 was re-admitted to the facility after a local hospital admission and R2 was started on hospice upon readmission. V11 stated, I don't know what their criteria are for that. Surveyor asked how she determined R2's pressure ulcer was a Kennedy ulcer, and if she had seen R2's sacral pressure ulcer prior to the day she diagnosed it as a terminal ulcer on [DATE]. V11 replied, I had not seen it prior to that. I was told he had 2 small areas a few days prior to that, and they changed fast, so I based it on that.On [DATE] at 2:58 PM, V6, CNA, stated R2 did not have a dressing on his sacrum when she worked on the weekend before R2 expired on [DATE]. V6 stated she told R2's nurse, and she replied R2 is dying and did not apply a dressing during her shift. V6 stated the mattress overlay provided by hospice remained in R2's closet and was never put onto R2's bed.On [DATE] at 11:25 AM, V14, Regional Nurse, stated all the facility mattresses are pressure relieving mattresses. V14 stated she would agree R2 developed 5 to 6 pressure ulcers between the dates of [DATE] and [DATE] when he passed away. V14 stated V18, Regional Nurse, looked for an air mattress in the facility shed on [DATE] and the facility didn't have any.On [DATE] at 1:18 PM, V19, LPN, stated she was R2's nurse on Saturday, [DATE], and hospice delivered the mattress overlay. V19 stated R2's daughter was at the facility when hospice delivered it, and she requested it be under her father/put on his bed, but the cord wouldn't reach the outlet, so she and the CNAS left the overlay on the table next to his bed. V19 stated she knew they would have to get it approved from management for some type of extension cord, but she is not sure what happened with it after that weekend.On [DATE] at 1:42 PM, V20, Maintenance Assistant, stated he did receive a note about R2 needing a power strip, and he placed a power strip on R2's wall for the air mattress hospice delivered the following week of [DATE].On [DATE] at 2:28 PM, V21, Hospice RN, stated she admitted R2 to their hospice program on [DATE] and saw him that weekend. V21 stated upon admission to hospice, R2 had 2 small pressure ulcers. V21 stated hospice initially provided an air overlay for R2, then she ordered a waffle overlay for his mattress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145500 If continuation sheet Page 3 of 5 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 10/08/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to prevent R2 from developing more pressure ulcers and to prevent his current pressure ulcers from getting worse. V21 stated as far as she knew, this facility did not have an issue with implementing waffle mattress overlays for residents. V21 stated she is not aware of the facility requesting any other type of mattress for R2, and the hospice does have multiple different kinds of pressure reducing mattresses available. V21 stated when she assessed R2 again shortly before he passed away, he was covered with multiple stage 1 and stage 3 pressure ulcers. Surveyor asked V21 if she feels in her professional experience R2 would have developed multiple pressure ulcers if the waffle mattress overlay would have been implemented, and V21 replied No, I don't think he would have developed multiple pressure ulcers. Surveyor asked V21 if she assessed R2's pressure ulcer of his sacrum as being a Kennedy ulcer and V21 replied, No, because all his wounds did not develop at the same time and although he was a dark skinned African American, the wound base looked like a stage 3 pressure ulcer to me not a Kennedy ulcer.On [DATE] at 2:55 PM, V1, Administrator, stated she would have expected someone to follow up on the air mattress.The facility's Skin Identification, Evaluation, and Monitoring Policy, dated 1/2025, documented, the purpose of this policy is to outline a method of identification, evaluation, and monitoring for alterations in skin integrity. Communities will implement preventative measures and an individualized care pan will be formulated upon completion of findings. Preparation: A. Review of resident medical record to identify risk factors that have the potential to cause alterations in skin integrity. It continues, Procedure: A licensed nurse will evaluate skin integrity through a physical skin evaluation upon admission, weekly, and when a significant change is identified. The nursing assistant will observe the resident's skin for breakdown using the risk assessment tool upon admission, weekly for 3 consecutive weeks (totaling 4), quarterly, and when a significant change is identified. It continues, A. Complete a weekly skin check to evaluate for changes in skin integrity. B. Document in medical record the finding of weekly skin assessment. A. If wounds are present and previously identified: i. Document integumentary findings in weekly skin assessment. ii. Appearance of the wound, including measurements if the wound is due for a treatment change. iii. Complete weekly re-evaluation of previously identified skin alterations/wounds. iv. Treatment applied/initiated per health care provider order in the medical record. b. If new wound is identified: i. initiate protective dressing. ii. Notify health care provider of finding and further treatment orders. iii. Notification/education of resident and resident representative of finding and physician orders. iv. Notification of community wound care nurse for evaluation and Director of Nursing. C. Document evaluation in the medical records. D. Update plan of care with each intervention. It continues, Interventions and Prevention: SKIN A. S.-Surface Selection a. Select surface based on resident assessment. b. Ensure all residents at risk of developing pressure injuries are placed on a pressure-reducing surface. c. Use pressure-reducing chair cushion for at risk resident. Skin Integrity Treatment Program: A. Eliminate or reduce a. the source of pressure using positioning techniques, enhancement of mobility and circulation, support of ancillary team members. b. other sources of skin injury by evaluating the cause and providing interventions. B. Pain control C. Preventative measures to reduce the risk of further tissue loss. D. Managing and reducing the risk of infections. E. Interventions that increase the potential for healing.The facility's Hospice Services policy, undated, documented, each resident will receive, and this facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. This facility provides continuity of care that recognizes the spiritual needs and to assist residents, family members ad friends to live as fully and completely as possible with meaning and dignity. It continues, Definitions: Hospice care means a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145500 If continuation sheet Page 4 of 5 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 10/08/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete comprehensive program of services provided to a terminally ill individual that emphasizes the management of pain and other physical symptoms, as well as management of the psychosocial needs of the dying individual and the family members. Hospice care plan means a written plan of care developed by the interdisciplinary team that describes the care to be provided, including a notice of those life sustaining procedures that are not to be used. It continues, Procedures: provide and periodically review resident plan of care, addressing services, and support that accommodate and honor the resident's choices and rights, manage pain and other physical, mental, and psychosocial symptoms, and strive to meet the resident's physical, mental, psychosocial, and spiritual needs. It continues, the facility will coordinate care planning with the hospice provider including all services and supplies provided by the hospice provider including durable medical equipment. The resident's quality of care and life will by enhanced by meeting the resident's emotional, spiritual and social needs including: hygiene/skin. Event ID: Facility ID: 145500 If continuation sheet Page 5 of 5