Health inspection·November 15, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Minimal harm or potential for actual harm Based Residents Affected - Some on interview and record review the facility failed to ensure residents were free of verbal and physical abuse for two residents (R1-R4) of five reviewed for abuse in a sample of five. Findings include: The facility's Summary of Abuse and Neglect Prevention policy, undated, documents staff's first responsibility is for the safety of the resident. The facility will not tolerate abuse or neglect of its residents by any individual including staff, family, volunteers or consultant. Abuse refers to any act willfully injuries or hurts a resident and includes unreasonable isolation, intimidation, or punishment of a resident. Examples of physical abuse would include hitting, kicking, pinching, choking, shoving, pushing, slapping, punching striking with an object, burning, hitting or a resident or inappropriate sexual language or conduct. This form also documents verbal abuse includes the use of words, signs, or gestures to intimidate, demean, harass, or threaten the resident. 1. R1's electronic face sheet documents the following diagnosis: Alzheimer's Disease with late onset, Anemia, Chronic Obstructive Pulmonary Disease, Disorientation, Macular Degeneration, Sciatica, Fatigue, Chronic Pain, Rhinitis, Weakness, Palpitations, History of Urinary Tract Infections, Radiculopathy of Lumbar Region, Rheumatoid Arthritis, Spinal Stenosis, Left Artificial Knee, Disease of the Digestive System, Peripheral Vascular Disease, Constipation, Chest Pain, Hypo-Osmolality and Hyponatremia, Atherosclerotic Heart Disease. R1's current care plan documents R1 is at risk for abuse as evidenced by Dementia, Hearing loss, personality characteristics, with being combative with cares. R1's goal is to be abuse free. R1's Progress Notes, dated 10/19/23 documents V13, R1's Family, called V1, Administrator, concerning care was given to R1 on 10/11/23. The facility's final notification of investigation of staff for physical/emotional abuse, dated 10/20/23, documents at V3, Assistant Director of Nursing, determined V5 Certified Nursing Assistant, took care of R1 on 10/11/23. V3 immediately escorted V5 out of the building. This form documents the allegation of physical/mental abuse is substantiated and V5 was terminated. On 11/16/23 at 9:30am, V9, R1's Caregiver, stated on 10/11/23, V9 asked V5, CNA/Certified Nursing Assistant, to transfer R1 from the recliner to her wheelchair. V9 stated V5 told R1 to put her hands around V5's neck. R1 did not understand V5, so V5 pulled R1's hands up and placed them on her (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: 145949 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 145949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Home 14688 Illinois Highway 82 Geneseo, IL 61254 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)