Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interview, facility failed to ensure sufficient nursing staff to provide nursing
and related services to meet the residents' needs safely and in a manner that promotes each resident's
rights, physical, mental, and psychosocial well-being. This failure has the potential to affect all 85 residents
residing in the facility.Findings include:The Resident Council Minutes, dated 11/05/25, documents the
facility needs to hire more night staff.The facility's Daily Staffing Sheet dated December 27, 2025,
documents V21, Registered Nurse, as the only nurse working facility on midnight shift.On 1/22/2026 at
11:03 AM, R3 stated the facility has problems with staffing and need to hire more staff. R3 stated it takes a
long time to answer the call light.R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively
intact.On 1/22/2026 at 11:08 AM, R5 stated, The facility does not have any staff and it's worse on nights.
Takes forever to get light answered.R5's MDS, dated [DATE], documents R5 is cognitively intact.On
1/22/2026 at 11:06 AM, R6 stated they need more staff. R6 stated the staff will tell them they are short, and
it takes a long time to get care.R6's MDS, dated [DATE], documents R6 is cognitively intact.On 1/28/2026 at
9:24 AM, V22, Staff Coordinator/Scheduler, stated V22 does the schedules for both the Certified Nurse
Assistants (CNAs) and Nurses. V22 stated she schedules for the census. V22 stated 4 nurses on days, 3 to
4 on evenings, and 2 on midnights. V22 stated they have had some staffing issues and she and the
Assistant Director of Nursing cover when there are call offs. V22 stated on 12/27/2025, she received a call
from the evening nurse saying her relief was not at the building. V22 stated she informed the nurse she
needed to stay. V22 stated she was informed no. V22 stated she tried offering bonuses and nothing. V22
stated she did not have a nurse to go in, and she is a CNA and cannot perform nurse duties. V22 stated for
the census and level of care, there should have been 2 nurses on shift.On 1/28/2026 at 10:48 AM, V20,
(CNA), stated V21 was the only nurse in the building for the entire night shift.On 1/28/2026 at 2:09 PM, V21
stated he was the only nurse for the entire building from around 11 PM. V21 stated the evening nurse said
she was leaving. V21 stated at that time, he refused to over the hall because he was the only nurse. V21
stated he informed the nurse to call and find out where was the relief. V21 stated he was informed the
facility staff was not responding, and the nurse left. V21 stated he made attempts to contact management,
and no one answered. V21 stated he left messages and no response. V21 stated the night was challenging;
he had residents with changes of conditions requiring hospitalization and no help. V21 stated he called to
notify of resident being transferred out and no response. V21 stated no one came.On 1/28/2026 at 2:30
PM, R13 stated staffing is bad and slow. R13 stated the facility uses a lot of agency staff, and they may or
may not show up, leaving the residents without care or poor care. R13 stated they need more of their own
staff.R13's MDS, dated [DATE], documents R13 is cognitively intact.On 1/28/2025 at 2:39 PM, V2, Director
of Nursing, stated the facility does not have a staffing policy.On 1/28/2026 at 2:40 PM, V1, Administrator,
stated the
(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 3
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
01/29/2026
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 0725
facility follows the CMS regulations.On 1/21/2026, the facility provided a Midnight Census report
documenting 80 residents residing in facility.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145500
If continuation sheet
Page 2 of 3
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
01/29/2026
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to properly store controlled medication
and discard expired medication for 7 of 7 (R1, R2, R3, R4, R5, R6, R7) residents reviewed for medication
storage in a sample of 13.Findings include:On 1/21/2026 at 9:28 AM, the facility Medication room was
inspected. Upon entrance to the medication room, the refrigerator was unlocked. The unlocked refrigerator
located in the medication contained:*R1's bottle of oral Lorazepam Concentrated solution.On 1/21/2025 at
9:34 AM, the 300 Hall medication cart was inspected. The medication cart contained the following:*R2's
open and partially used Insulin Glargine Solution vial. 1/5 was handwritten on the vial. The expiration date
November 2025.On 1/21/2025 at 9:44 AM, V4, Registered Nurse (RN), stated the handwritten date was the
date it was opened, 1/5/26. V4 verified the vial was open, in use, and expired November 2025.On
1/21/2026 at 9:50 AM, the 200 Hall medication cart was inspected. The lock box was unlocked and able to
be opened by lifting the lid with a finger. The open and unlocked lock box contained the following:*1 open
and partially used bottle with 19.25 ml of R1's Morphine Sulfate Oral Solution and 1 unopen bottle with 30
mls of R1's Morphine Sulfate Oral Solution.*1 open and partially used bottle with 1.5 ml of R1's Lorazepam
Concentrated solution.* 1 card with 14 of R3's Oxycodone 5mg/325 mg tablets.*1 card with 20 of R3's
Hydrocodone/APAP 5mg/325mg tablets.* 1 card with 14 of R4's Alprazolam 0.25mg tablets.* 1 card with 25
of R5's Hydrocodone/APAP 7.5mg/325mg tablets.*1 card with 6 of R6's Tramadol 500mg HCL tablets.* 1
card with 30 of R6's Tramadol HCL 500 mg tablets.*1 card with 8 of R7's Lorazepam 0.5mg tablets.On
1/21/2026 at 9:51 AM, V5, Licensed Practical Nurse, LPN, stated at times, the lock gets stuck and doesn't
latch. V5 performed a count of the narcotics and verified R1's medication was open and partially used; R3's,
R4's, R5's, R6's, and R7's medication was in the unlocked lock box and in use.On 1/22/2026 at 9:35 AM,
V9, LPN, stated all narcotics and controlled are under a double locked system. V9 stated the controlled
medication in the refrigerator would be under a double locked system. The medication room is locked, and
the refrigerator is locked as well. V9 stated the medication cart is the same. V9 stated the controlled
medication is stored in a locked drawer, and when not in use, the cart is locked. This creates the double
locked system. V9 stated insulins expiration dates are on the vial or pen. V9 stated this date is checked
prior to opening. If the medication is expired, it would not be used and discarded. The facility's Storage and
Return of Drugs policy, dated 4/21, documents A. Drug supplies for the facility shall be stored under proper
conditions, sanitation, temperature, light, refrigeration, and moisture. B. Residents' medications shall be
properly labeled and stored at or near the nurse's station in a locked cabinet, a locked medication room, or
in one or more locked mobile medication carts of satisfactory design for such storage. All mobile medication
carts shall be under the visual control of the responsible nurse at all times when not stored either in a
locked room or otherwise made immobile. D. Biologicals or medications requiring refrigeration shall be kept
in a separate securely fastened box within a refrigerator, locked refrigerator, or in a refrigerator within a
locked room. Such refrigerator shall contain a thermometer to ensure proper temperature for medication
storage. Refrigerators used for medication storage should not be used for personal storage of food/drinks.
E. Multi-dose vials and pens shall be stored and dated per the manufacturers guidance.The facility's
Schedule II Drugs policy, dated 4/21, documents D. Schedule II controlled substances shall be stored in
such manner so that two (2) separate locks, using two (2) different keys, must be unlocked to obtain these
substances. This may be accomplished by using a locked cabinet within a locked room.
Event ID:
Facility ID:
145500
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
FAQ · About this visit
Common questions about this visit
What happened during the January 29, 2026 survey of HILLSBORO REHAB & HCC?
This was a inspection survey of HILLSBORO REHAB & HCC on January 29, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HILLSBORO REHAB & HCC on January 29, 2026?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.