Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility quarantined 6 residents to remain in their rooms (R1,
R21, R36, R43, R53 and R59) on 5/28/24 without any clear reasoning. This failure caused R53 to be very
upset and anxious regarding his inability to leave his room.
Findings Include:
The Facility's Policy for Outbreak Investigation dated 4/1/2024 documents, It is the policy of (This Facility)
that outbreak measures will be instituted whenever there is an incidence of infections above what would
normally be expected, considering seasonal variations. The Infections Preventionist will conduct the
outbreak investigation.
The Facility's Your Rights and Protections as a Nursing Home Resident pamphlet dated 8/2021 documents,
You have the right to be treated with dignity and respect, as well as make your own schedule and
participate in the activities you choose You have the right to decide when you go to bed, rise in the morning,
and eat your meals.
Upon entry to the facility on 5/28/24 at 8:45AM no staff members were wearing masks and V20
(Receptionist) stated there were no known outbreaks or illnesses happening in the building at that time. At
this time, R53 was in the main dining room eating breakfast with three other male residents. R53 appeared
to be friendly and talkative with these men.
R53's admission Activity Assessment dated 6/21/2022 documents, R53 prefers to be with people and
enjoys large groups and small groups.
On 5/28/24 at 9:00AM multiple staff members were observed passing out surgical masks to other staff
members instructing them that we are in outbreak status we need to mask.
On 5/28/24 at 11:00 AM V3 (Registered Nurse/Assistant Director of Nurses/Infection Preventionist) stated, I
decided we have had some upper respiratory infections lately, so I am having the staff mask to be careful.
V3 did not indicate at that time that residents were being asked to remain in their rooms.
On 5/28/24 at 3:15 PM V6 (Licensed Practical Nurse) stated, This is ridiculous. We have had allergic rhinitis
in this building for the past couple of weeks because it is that time of year. Nothing has changed other than
(Survey Agency) coming in for an inspection. V6 stated, (R53) is very mad about having to stay in his room.
(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 7
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
05/31/2024
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)
F 0550
Level of Harm - Actual harm
Residents Affected - Few
On 5/28/24 at 3:30 PM R53 stated, What the hell is this all about? I have been hacking and coughing for at
least a week and now that I am starting to feel better. I have to stay in my room? I am almost [AGE] years
old, if I die, I die. I would rather eat in the dining room than be made to sit in my room looking at the wall
while I am eating. If I am so contagious, why is he (R62/roommate) still alive and able to leave the room?
This is infuriating that no one here knows what the hell they are doing. Pure chaos.
On 5/29/24 at 8:30 AM V5 (Licensed Practical Nurse) stated, (R53) is very irritated with staying in his room.
V5 confirmed, (R53) had been hacking for the past week or so. V5 stated, Everyone has had that allergy
cough going on. (R53) actually sounds better than he has. (R1) is one of them that we were instructed to
keep in her room, and she sounds no different than she ever has. I just don't understand the reasoning on
any of these.
On 5/29/24 at 9:15 AM R53 was sitting inside of his room speaking with V7 (Social Services Director)
saying, When am I getting out of here? I need to shower. I want to go to the dining room. If the risk is mine, I
will take it, if it is because I am infectious, I think we may have killed (R62/Roommate).
On 5/29/24 at 9:20 AM V7 (Social Services Director) confirmed R53 had been upset and wanting
information regarding when he could leave his room. V7 confirmed that both R53 and his roommate R62
are up and about their room independently and neither of them was wearing masks inside of the room. V7
confirmed R62 was free to come and go from the room as he wished and that she didn't know when R53
would be able to leave his room. That is up to (V3 RN/ADON/IP).
On 5/30/24 at 10:30 AM V3 (Registered Nurse/Assistant Director of Nurses/Infection Preventionist) stated
she implemented masking because there had been an uptick of respiratory issues at the facility over the
weekend. V3 confirmed she instructed staff members to keep R1, R21, R36, R43, R53 and R59 in their
rooms related to upper respiratory symptoms. V3 confirmed she did this prior to completing any
investigation into duration of symptoms, fever status or speaking with floor staff regarding status of the
residents who were being asked to stay in their rooms. V3 stated, I found out (R53) was upset, I just didn't
have time to investigate it right then. V3 confirmed that after her investigation into R53's respiratory status
he could have come out of his room with a mask on himself and did not need to be kept in his room. V3
confirmed R53 was encouraged to stay in his room on 5/28/24 for lunch and supper meals and on 5/29/24
for the breakfast meal unnecessarily. V3. Stated, I over reacted and I owe (R53) an apology because he
was so upset.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145949
If continuation sheet
Page 2 of 7
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
05/31/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on interview, observation and record review, the facility failed to ensure fall interventions were
implemented to prevent further falls for one of four residents (R38) reviewed for falls in the sample of 29.
Residents Affected - Few
Findings include:
The facility's Fall Reduction Program policy (revised 09/01/21) documents the following: All residents will
receive adequate supervision, assistance and assistive devices to aid in the prevention of falls. Each
resident will be evaluated for safety risks including falls and accidents. Care Plans will be created and
implemented based on the individual's risk factors to aid in the prevention of falls.
On 05/28/24 at 10:10 AM, R38 was lying in a low bed with a fall mat in place next to her bed. R38 was
nonverbal and did not respond to verbal stimuli when approached due to her impaired cognition.
R38's Fall Investigation (dated 01/08/24) documents the following: Nurse notified at this time of resident
(R38) sliding out of chair in dining room. CNA (Certified Nursing Assistant) stated resident slid out of chair
and did not hit head.
R38's current care plan documents the following focus: Risk for falls characterized by history of falls/injury,
multiple risk factors related to: impaired balance, poor coordination, poor safety awareness. This same care
plan documents the following fall prevention intervention: 01/08/24: Re-educated staff to ensure (R38) has
(non-slip mat) placed under her.
On 05/30/24 at 02:00 PM, V17 (Licensed Practical Nurse/Care Plan Coordinator) stated that after
investigation of R38's 01/08/24 fall, R38 did not have (non-slip mat) in place in her wheelchair and should
have had it in place since it had been a previously implemented fall prevention intervention. V17 stated that
staff was re-educated to check above and underneath R38's wheelchair cushion to ensure (non-slip mat) is
in place.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145949
If continuation sheet
Page 3 of 7
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
05/31/2024
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on observation, record review and interview the facility failed to ensure psychotropic medications
given on an as needed basis were not prescribed more than 14 days for 1 resident (R27) of 5 residents
reviewed for unnecessary medications in a total sample of 29.
Findings include:
The facility's Policy / Procedure regarding Treatment/Services for Mental/Psychosocial Concerns dated
11/18/21 documents, A resident who displays or is diagnosed with dementia, receives the appropriate
treatment and services to attain or maintain his or her highest practicable physical, mental, and
psychosocial well-being.
R27's Physician Order Sheet (POS) dated May 30, 2024 documents R27 is prescribed Lorazepam 0.5
milligrams by mouth every eight hours for anxiety.
On 05/28/24 at 9:38 AM R27 was observed laying quietly in her bed on her left side. R27 was asleep and
having no behaviors.
On 05/28/24 at 12:23 PM, R27 was noted laying in her bed quietly, having no behaviors.
On 05/30/24 at 11:09 AM, R27 was sitting in a wheelchair in the dining room at a table with two other
residents and a staff while eating her lunch independently. R27 was not noted to have behaviors.
On 05/30/24 at 11:07 AM V18, Certified Nursing Assistant, stated R27 sometimes hallucinates but is not
aggressive nor displays self-injurious behavior.
On 05/30/24 at 1:00 PM, V8, Licensed Practical Nurse/LPN, stated R27 had behaviors when she was new
to the facility and the environment was different to her, however, typically her behaviors are an indicator of
the beginning of a urinary tract infection or sometime similar.
R27's Medication Administration Records document the last time she was administered Ativan on an as
needed basis was February 15, 2024.
A Note to Attending Physician/Provider documents R27 has an as needed (PRN) psychotropic order for
Ativan 0.25 mg (milligrams) q8h prn (every eight hours as needed). Previously documented stop date of
04/23/24 will expire soon. 6 months is handwritten into the area for duration and dated 04/18/24.
On 05/30/24 at 2:07 PM, V17, LPN, stated, It is not in our policy for a PRN psychotropic to not be ordered
for more than 14 days, but it is our practice.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145949
If continuation sheet
Page 4 of 7
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
05/31/2024
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)
F 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure their Antibiotic Stewardship program was
implemented. this failure has the potential to affect all 62 residents residing at the facility.
Residents Affected - Many
Findings include:
The facility's Antibiotic Stewardship Program policy (undated) documents the following: Infection
Preventionist will encourage and educate staff to use McGeer's definitions of infections. Standards of
infection observation are checking for signs observed and/or resident has a change of condition. The
following steps will be implemented: monitor vital signs, monitor intake and output for 48 hours, assessment
of lung sounds, and assessment of other signs of infection and update the physician and family. If UTI
(urinary tract infection) is suspected, then 48 hour watch will be implemented by monitoring temperature,
intake and output, urine color and character, pain assessment and changes in mental status using
McGeer's definition as a guide.
On 05/29/24 at 09:20 AM, V3 (Registered Nurse/Infection Preventionist) stated the facility does not
implement any protocols to review clinical signs and symptoms and/or laboratory reports prior to
implementation of an antibiotic for a resident. V3 stated the facility does not utilize any assessment tools or
management algorithms to determine if an antibiotic is warranted, We just call the doctor and get an order
for an antibiotic if we believe one is needed.
The facility's Long Term Care Facility Application for Medicare and Medicaid, Form 671, dated 05/28/24 and
signed by V1 (Administrator), documents 62 residents currently reside in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145949
If continuation sheet
Page 5 of 7
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
05/31/2024
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)
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
Based on document review, observation and interview, the facility failed to ensure call lights were equipped
to communicate directly to staff. This failure has the potential to affect all 62 residents residing in the facility.
Residents Affected - Many
Findings include:
The Software User Guide dated 2020 documents the web-based application is designed for nurse call and
wander management use for Independent and Assisted Living facilities. The Guide documents to log-into
the application with username and password. When the Alarms (nurse call or wander alarms) are activated,
the computer will make a sound and display the location of the alarms.
On 5/28/24 at 10:58 AM, R25 stated, I have to help when I go number two. I have waited up to 70 minutes
for them (staff) to respond to my light. I would say the average wait time is between 30 minutes to 70
minutes.
On 05/28/24 11:10 AM, R17 stated, The call light response time could be better. Especially in the morning
when they are so busy. Sometimes you have to wait a really long time for help.
On 5/29/24 at 11:45 AM, V10 Registered Nurse) demonstrated at the nurse's station a device called Code
Alert which the screen will light up a resident's room number when the nurse call is activated or identify a
resident's location if the wander guard alarm is activated. V10 stated, the computers will also notify the
Nurses and/or Certified Nurse Aides (CNA) in the same manner. V10 stated, You (Nurses and CNA's) have
to be at the desk (nurse's station) or at their computer to know if a resident needs assistance.
On 5/29/24 at 12:00 PM, V12 (Physical Therapist) and V13 (Occupational Therapist) stated call light
response time could be a lot better especially when a resident is toileting. V13 stated, We (Therapy) used to
be able to help with call lights and toileting but ever since they switched to this new system, we are not
alerted to when they (nurse calls) are on.
On 5/29/24 at 1:34 PM, R25's nurse call was activated. At 1:37 PM, V17 (Licensed Practical Nurse) was
observed to enter R25's room and state Music is in the Activity Room at 2:00 PM. V17 did not address
and/or was not aware the nurse call was activated.
On 5/29/24 at 1:45 PM, V14 (CNA), V15 (CNA), and V16 (CNA) were observed in the [NAME] Hall with a
computer and demonstrated the use of the nurse call system. A call light was activated; an alert was
displayed with the room number and location and a sound was heard. V16 stated, If we are not at the
computer, we turn the sound on the computer up, but we still have to come out and look to see where the
alarm is.
On 5/29/24 at 1:55 PM, V8 (Licensed Practical Nurse/LPN) stated the computers time out (of the nurse
call/wander guard software application) in one or two hours.
On 5/29/24 at 1:55 PM, V5 (LPN) stated, If a call light (nurse call) is shut off in the room, it's still on in the
system and we have to restart the system. Sometimes the call light gets stuck on, and we have to restart
the system. It's (software application) kinda squirrely sometimes. It worked a lot better when we could just
see the lights.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145949
If continuation sheet
Page 6 of 7
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
05/31/2024
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)
F 0919
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
On 5/30/24 at 9:45 AM, V1 (Administrator) stated if the wi-fi or power is lost, the facility has bells to give the
residents and 15-minute checks are conducted.
On 5/30/24 between 10:29 AM and 10:40 AM, two computers in the South Hall, one computer in the
[NAME] hall and one computer in the East hall displayed two alarm notifications (1 notification on for 18
minutes in 3 North bathroom, 1 notification on for 9 minutes in 7 [NAME] bathroom) although no sound was
heard.
On 5/30/24 at 10:40 PM, V18 (CNA) stated, The volume was turned down because it's annoying.
The following observations lacked nurse call monitoring by a nurse or CNA: The North Hall- on 5/28/24
between 10:20 AM and 11:00 AM, 12:00 PM and 12:30 PM; On 5/29/24 between 11:45 AM and 11:59 AM,
12:10 PM and 1:30 PM - 1:39 PM; 5/30/24 between 9:29 AM and 9:35 AM and 10:34 AM. The East Hall- on
5/29/24 at 1:40 PM and 5/30/24 at 9:29 AM. The South Hall- 5/29/24 at 1:29 PM and 5/30/24 at 9:28 AM.
The Resident Census dated 5/28/24 documents that 62 residents currently reside in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145949
If continuation sheet
Page 7 of 7
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Back to topCitations
5 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.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
FAQ · About this visit
Common questions about this visit
What happened during the May 31, 2024 survey of HILLCREST HOME?
This was a inspection survey of HILLCREST HOME on May 31, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HILLCREST HOME on May 31, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Implement a program that monitors antibiotic use."
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.