Health inspection·June 24, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to notify a physician of a fall in a timely manner and failed to notify the physician of the resident taking an anticoagulant medication for 1 of 3 residents (R2) reviewed for notification of changes in the sample of 4. The findings include: The admission record for R2 shows she was admitted to the facility on [DATE] with multiple diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic atrial fibrillation, unspecified dementia, and aphasia (communication disorder). The facility's 4/29/24 admission assessment of R2 shows severe cognitive impairment. The same assessment shows R2 to be on an anticoagulant medication. The order summary report of 6/23/24 shows R2 was taking Eliquis 2.5 mg twice daily for chronic atrial fibrillation. R2's progress notes for 6/22/24 at 3:15 PM show resident observed on the floor on the side of the bed in front of her wheelchair sitting upright onto buttocks. Vital signs obtained, and remain within normal limits of baseline, full body observation completed with no injury noted, resident denied hitting head, however fall was unwitnessed, so neuro checks in place. MD notified via fax and made aware, with instructions to continue to monitor per facility protocol. On 6/23/24 at 11:25 AM, V16 CNA (Certified Nursing Assistant) said R2 only knows her name, is confused, and wanders around the facility. R2 would not be able to answer any questions correctly such as if she hit her head during a fall. On 6/23/24 at 12:07 PM, R2 was observed sitting in the hallway after lunch. R2 stated she did not have lunch, after observing staff feeding her lunch. R2 denied having any falls and was oriented to her name only. R2 stated the month/year as October 1939, and it was summer. The Communication for Doctor and Nursing home staff form dated 6/22/24 shows the MD was notified at 8:00 PM, 5 hours after the unwitnessed fall. The nurse noted R2 was assisted off the floor, alarm sounding, ROM (range of motion) WNL (within normal limits). No complaints of pain or discomfort. Skin assessment done, vital signs WNL. Will monitor. Neuros initiated. The document does not include the resident was prescribed anticoagulant medications. The fall risk assessment completed by V14 LPN (Licensed Practical Nurse) documents R2 had been in (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 06/24/2024 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)