Hillsboro Rehab & HCC

Inspectors wroteBased on record review and interview, the facility failed to prevent abuse for 3 of 3 residents (R1, R12, and R17) reviewed for abuse in the sample of 17. This past non-compliance occurred from 5/3/2026-5/5/2026.

Inspectors wroteBased on interview and record review, the facility failed to prevent theft from occurring for 2 of 3 residents (R4, R5); reviewed for Misappropriation in a sample of 17. This Past Non-Compliance occurred from 6/15/26 through 6/25/26.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide timely and accurate wound care for 2 of 3 residents (R6, R11); reviewed for quality of care in a sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to administer intravenous antibiotics to treat osteomyelitis in 1 of 3 residents (R7) reviewed for Medication Errors in a sample of 17.

Inspectors wroteBased on interview, observation, and record review, the facility failed to perform hand hygiene and follow Enhanced Barrier Precautions (EBP) for 3 of 6 residents (R15, R16, R13); reviewed for Infection Control in a sample of 17.

Inspectors wroteBased on interview and record review, the Facility failed to prevent physical abuse in 4 of 4 residents (R1, R4, R5, R7) reviewed for abuse in the sample of 7. This past non-compliance occurred from 1/24/26 to 2/27/26.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent abuse from occurring and failed to document progressive interventions for 3 of 3 residents (R3, R7, R9) reviewed for abuse in the sample of 10. These failures resulted in R3 having R4's hands around her neck aggressively, R7 being hit in head by R4 and also being pushed down in chest by R4 while in bed, and R9 being slapped by R4. Using a reasonable person concept, R3, R7, and R9 would experience discomfort/pain and feelings of being scared, unsafe, shame, and humiliation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to transfer 1 (R5) of 3 residents properly and failed to update a resident's care plan (R10) with progressive interventions to prevent future falls for 2 residents reviewed for accidents and falls in the sample of 3. These failures resulted in R5 having swelling and bruising to left ankle/lower leg and being diagnosed with an acute on chronic distal tibial fracture.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's emergency contact after an injury was sustained for 1 (R5) of 3 residents reviewed for notification.

Inspectors wroteBased on interview and record review, the facility failed to implement end of life/hospice skin care plan interventions for 1 of 3 (R2) residents reviewed for pressure ulcers in the sample of 5. This failure resulted in R2 developing multiple in-house acquired pressure ulcers between the dates of [DATE] and [DATE] when R2 expired at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of verbal abuse were reported immediately to the Administrator of the facility and in a timely manner to the State Agency for 1 of 3 residents (R2) reviewed for verbal abuse in a sample of 5. Findings Include: R2's Face Sheet, original admission date of 11/21/22, documented R2 has diagnoses of but not limited to cerebral infarction, type II diabetes mellitus, major depressive disorder, and hypertension (HTN). R2's Minimum Data Set (MDS), dated [DATE], documented R2 is cognitively intact, with a Brief Interview for Mental Status (BIMS) of 13 out of 15, and requires some assistance with her activities of daily living (ADLs). On 06/24/25 at 9:25 AM, R2 said V4, Social Service Director (SSD), yelled at her and she didn't want to talk about it. [...]

Inspectors wroteBased on interview and record review, the Facility failed to provide showers for 1 of 3 residents (R1) reviewed for showers, in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs for 1 of 3 residents reviewed for staffing in a sample of 6. This has the potential to affect all residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to supervise and provide showers as scheduled for 4 of 4 (R1, R2, R3, R5) residents in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to to provide restorative services for 1 of 3 residents (R3) reviewed for nursing programs in a sample of 5.

Inspectors wroteBased on Interview and Record Review the facility failed to ensure a resident was free from abuse, from a resident with a history of prior altercations, for 1 of 6 (R4) residents reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse from occurring for 2 of 2 residents (R2, R3) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to notify law enforcement of an allegation of sexual assault for 1 of 1 resident (R2) reviewed for reporting abuse in a sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of abnormal blood sugars as ordered in 1 of 8 residents (R2), reviewed for pharmacy services in the sample of 8. Findings Include: R2's Medical Diagnosis Listing, undated, documents R2 has a diagnosis of Type 2 Diabetes Mellitus. R2's Physician Order Sheet documents the following order, dated 12/13/24 through 12/15/24, Novolin 70/30 Subcutaneous Suspension (70-30) 100 Units/ML (Milliliter). Inject as per sliding scale: if 80 - 100 = 7; 101 - 150 = 9; 151 - 200 = 11. Call MD (Medical Doctor) if blood sugar is greater than 200, subcutaneously in the morning. Inject as per sliding scale: if 80 - 100 = 7; 101 - 150 = 6; 151 - 200 = 8 Notify MD greater than 200, subcutaneously in the evening. R2's Blood Sugar Record documents the following: 12/14/24 at 11:08 AM, blood sugar of 215; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform wound care on 1 of 3 residents (R2), reviewed for quality of care in the sample of 8. Findings Include: R2's Medical Diagnosis Listing, undated, documents R2 was admitted to the facility with a diagnosis of Orthopedic Aftercare following a Right Femur Fracture. On 12/18/24 at 9:30 AM, wound care was observed with V3, ADON(Assistant Director of Nurses)/Wound Nurse/IPC (Infection Control Preventionist) . R2 has 3 incisions to the right hip. There was a dressing, dated 12/18/24, covering the two lower incisions. There was no dressing in place to the upper incision. All incision areas had staples in place. On 12/18/24 at 8:30 AM, R2 stated he thinks the nurses look at his hip incision, but don't put a dressing on it every day. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopements for 1 of 8 residents (R49) reviewed for supervision to prevent elopements in a sample of 57. This failure resulted in an Immediate Jeopardy when on 8/17/24 at an unknown time, R49, who has a known history of elopement attempts and dementia, eloped from the facility without staff knowledge and was located 60 miles away from the facility. The Immediate Jeopardy began on 08/17/24 when R49 eloped from the facility without staff knowledge. R49 was last seen in the facility on 8/17/24 at 11:30 , and was found 60 miles away at his past home residence. Due to R49's physical and cognitive vulnerabilities, R49 had the likelihood of serious harm and injury when R49 eloped. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the verbal and physical resident to resident abuse for 4 of 4 residents (R17, R31, R32, R49) reviewed for abuse in the sample of 57. This failure resulted in R49 grabbing a large fist of R32's hair and pulling it out of her scalp.

Inspectors wroteBased on interview, observation, and record review, the facility failed to dispose of an open multi-dose vial of Insulin after 30 days, failed to dispose of an expired bottle of stock medication, and failed to date an open vial of Tuberculin that is used by all staff and residents. This failure has the potential to affect all 93 residents in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to perform proper hand hygiene and/or the changing of gloves while plating food, failed to date food when opened and/or cooked, and failed to check and maintain the temperatures of the food, including all diets (regular diets, special diets, and pureed foods) prior to serving the residents to prevent contamination and foodborne illness. These failures have the potential to affect all 93 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure their facility assessment was updated to include all necessary components per the current standards of practice. This failure has the potential to affect all 93 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff donned/doffed Personal Protective Equipment (PPE) on the COVID-19 positive hallway, in a manner to prevent cross contamination; failed to ensure residents were not exposed to staff exhibiting symptoms of COVID-19; failed to implement transmission-based precautions for residents that were COVID-19 positive who were mobile throughout the unit including the hallway and dining/day areas; failed to ensure COVID negative residents were not exposed to COVID positive residents; failed to cohort positive COVID-19 residents together and instead cohorted positive and negatives together; failed to ensure signage posted indicating a positive COVID status; failed to offer/educate COVID vaccinations for residents and staff since 2022; [...]

Inspectors wroteBased on interview and record review, the facility failed to offer, provide, and track COVID vaccines, boosters, and immunizations. This failure has the potential to affect all 93 residents residing in the building. The Findings Include: V2, Director of Nursing (DON), is the facility's Infection Preventionist (IP), with a Certification on file dated 4/3/22. V8, Assistant Director of Nursing (ADON), is also the facility's IP with a Certification on file, dated 6/27/24. On 9/18/24 at 10:25 AM, V2 stated, Both me and (V8) are certified Infection Preventionist for this facility, but (V8) does most of the work with it. On 9/18/24 at 1:25 PM, when asked about resident Influenza and other resident vaccinations, V8 stated, We just received the Influenza vaccination this past Thursday (9/12/24). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Nurse Aides completed the required 12 hours of education per year. This has the potential to affect all 93 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide education, obtain consents, and administer influenza vaccine to 4 of 8 residents (R61, R77, R82, R23) reviewed for immunizations in the sample of 57. The Findings Include: 1. R61's admission Record, undated, documents R61 was originally admitted to the facility on [DATE], with diagnoses of Dementia, Sepsis, Cellulitis, Emphysema, Dysphagia, Psychotic disorder, Chronic Kidney Disease, and COVID-19. R61's Care Plan, dated 7/18/24, documents R61 is incontinent of bowel and bladder. Interventions: Check R61 for incontinence, wash, rinse and dry perineum, change clothing PRN after incontinence episodes, monitor/document for s/sx (signs/symptoms) UTI: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents during abuse investigations to prevent further potential abuse from occurring for 2 of 4 residents (R17, R31) residents reviewed for investigation/prevention/correct alleged violation of abuse in a sample of 57.

Inspectors wroteBased on interview and record review, the facility failed to document in the resident's Electronic Medical Record (EMR) the reason for discharge, failed to provide written documentation of the reason for discharge and resident rights to appeal the discharge to for 1 of 3 residents (R20) residents reviewed for discharge in a sample of 57.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure showers, basic grooming, and feeding assistance were provided for 2 of 24 residents (R33 and R145) reviewed Activities of Daily Living (ADLs) in the sample of 57.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to prevent the deterioration of pressure ulcer, the development of a new pressure, and treat pressure ulcers as order by physician for 1 of 2 residents (R85) reviewed for pressure ulcers in the sample of 57.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to provide timely toileting and incontinent care to prevent potential urinary tract infections (UTIs) for 3 of 3 residents (R145, R85, and R23) reviewed for incontinent care in the sample of 57.

Inspectors wroteBased on interview and record review, the facility failed to monitor and provide services for residents who verbalizes suicide threats for 1 of 1 resident (R31) reviewed for behavioral health services in the sample of 57.

Inspectors wroteBased on interview and record review, the facility failed to monitor, track, and properly document microbiology organisms on infection control log, and failed to monitor and follow up for proper antibiotic use for 2 of 6 residents (R10, R61) reviewed for Antibiotic Stewardship in the sample of 57. The Findings Include: 1. R10's admission Record, undated, documents R10 was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease, Dementia, Falls, and COVID-19. R10's Care Plan, dated 7/12/24, documents R10 is incontinent of bowel and bladder. Interventions: : Check frequently for incontinence, wash, rinse and dry perineum, change clothing PRN (as needed) after incontinence episodes, monitor/document/report to MD (Medical Doctor) PRN possible medical causes of incontinence: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Administrator of an allegation of abuse immediately for 1 of 3 residents (R1) reviewed for abuse in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent resident to resident physical abuse for 6 of 6 residents (R2, R3, R4, R8, R9, and R13) reviewed for abuse in the sample of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the resident's environment in a clean and sanitary condition.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain a resident's dignity in 1 of 4 residents (R2) reviewed for resident rights in the sample of 4. This failure resulted in R2 having a negative impact on her self-esteem and self-worth.

Inspectors wroteBased on interview, observation, and record review, the facility failed to thoroughly investigate an allegation of abuse in 1 of 4 residents (R2), reviewed for abuse in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinent care in order to maintain the resident's dignity, as well as prevent a resident from experiencing embarrassment due to incontinence, for 3 of 16 residents (R6, R23, and R25) reviewed for respect/dignity and personal worth in the sample of 34. This failure resulted in R6 feeling angry, R23 feeling lousy, and R25 being embarrassed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the Registered Dietician's recommendations and care plan interventions, resulting in a severe weight loss of 16.47% in a period of six months for 1 of 3 residents (R40) reviewed for weight loss in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent and contain flies, for 4 of 4 (R32, R43, R74, R134) residents, reviewed for pest control, in a sample of 34. This failure has the potential to affect all residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform timely and complete incontinent care for 6 of 6 (R6, R23, R25, R35, R49, R75) residents reviewed for incontinent care in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer assistance to shave facial hair for 2 of 5 (R6 and R134) residents, reviewed for activities of daily living in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform safe transfer for 3 of 3 (R35, R36, R74) residents reviewed for transfer in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity, had needs met timely, and provide privacy for 4 of 18 (R44, R46, R53, R175) residents reviewed for resident rights in the sample of 51. These failures resulted in R46 having feelings of embarrassment and she doesn't matter, R175 having feelings of embarrassment and crying when talking about her experience of being exposed and with not receiving timely care, and R53 being upset and feeling dirty.

Inspectors wroteBased on interview, observation, and record review, the facility failed to notify the Physician of a change of condition in a timely manner for 2 of 18 residents (R20, R40) reviewed for Physician notification in the sample of 51. These failures resulted in R40 having an infected surgical site that led to the incision site opening up, R40's having swelling causing pain, and R40 needing antibiotics; and R20 having a significant weight loss. Findings Include: 1. R40's Health Status Note, dated 6/23/22 at 1:30 PM, documents, Resident returned to facility after surgery via transportation driver. VS (Vital Signs) stable and no c/o (complaint of) voiced, denies any pain at this time. New orders for follow up appointment with (V50) at (local hospital) on July 12th at 4:00 PM. New order to leave dressing on left hand for 24 hours then remove it. Will continue to monitor. [...]

Inspectors wroteBased on interview, observation, and record review, the facility neglected to provide timely treatment for a surgical wound for 1 of 18 residents (R40) reviewed for neglect in the sample of 51. This failure resulted in R4's wound swelling, causing increasing pain, and the wound becoming infected and opening up. Findings Include: R40's Health Status Note, dated 6/23/22 at 1:30 PM, documents, Resident returned to facility after surgery via transportation driver. VS (Vital Signs) stable and no c/o (complaint of) voiced, denies any pain at this time. New orders for follow up appointment with (V50) at (local hospital) on July 12th at 4:00 PM. New order to leave dressing on left hand for 24 hours then remove it. Will continue to monitor. R40's Discharge Instructions from the local hospital for Excisions, dated 6/23/22, documents, Incisional Care: [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to act on a change of condition for 1 of 18 residents (R40) reviewed for nursing care in the sample of 51. This failure resulted in R40 experiencing increasing pain with swelling, and R40's surgical wound becoming infected and opening up. Findings Include: 1. R40's Health Status Note, dated 6/23/22 at 1:30 PM, documents, Resident returned to facility after surgery via transportation driver. VS (Vital Signs) stable and no c/o (complaint of) voiced, denies any pain at this time. New orders for follow up appointment with (V50) at (local hospital) on July 12th at 4:00 PM. New order to leave dressing on left hand for 24 hours then remove it. Will continue to monitor. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide adequate supervision to prevent falls, and failed to operate a mechanical lift in a safe manner in 3 of 6 residents (R19, R38, R226) reviewed for falls in the sample of 51. This failure resulted in R38 and R226 sustaining falls which resulted in fractures. 1. R226's face sheet, undated, documents a diagnosis of Parkinson's Disease and Muscle Weakness. R226's Minimum Data Set (MDS), dated [DATE], documents R226 has severe cognitive impairment, requires an extensive assistance of two staff for toileting and has had falls prior to admission and after admission. R226's care plan, dated 6/10/22, documents R226 is at risk of falls. R226's fall risk assessment, dated 6/10/22, documents R226 is at risk of falls. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor and provide interventions to prevent significant weight loss for 1 of 3 residents (R20) reviewed for weight loss and nutrition in the sample of 51. This failure resulted in R20's severe weight loss of 10% in 3 months, and severe weight loss of 11.7% in 6 months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address pain for infected, swollen surgical incision, and provide treatment to prevent skin irritation for 2 of 3 (R40, R72) reviewed for nursing care in the sample of 51. This failure resulted in R40 not having her new pain addressed for 6 days. Findings Include: 1. R40's Health Status Note, dated 6/23/22 at 1:30 PM, documents, Resident returned to facility after surgery via transportation driver. VS (Vital Signs) stable and no c/o (complaint of) voiced, denies any pain at this time. New orders for follow up appointment with (V50) at (local hospital) on July 12th at 4:00 PM. New order to leave dressing on left hand for 24 hours then remove it. Will continue to monitor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have adequate numbers of staff to meet the needs of the residents, including adequate supervision to prevent falls. This failure has the potential to affect all 81 residents living in the facility.

Inspectors wroteBased observation and interview, the facility failed to have a Registered Nurse (RN) to serve as a full-time Director of Nurses (DON). This failure has the potential to affect all 81 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to properly store and label medications, protein supplements, and tuberculosis test vials. This has the potential to affect all 81 residents in the Facility.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 81 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control guidelines were implemented, including those to prevent and/or contain COVID-19 and other infections by: staff not wearing appropriate masks and eye protection, staff not performing hand hygiene and glove [NAME] during care, staff not sanitizing multi use surfaces 9 of 18 (R19, R24, R30, R43, R44, R50, R53, R66, R175 ) residents reviewed for infection control in a sample of 51. These failures have the potential to affect all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to employee an infection control preventionists to oversee the infection prevention control program. This has the potential to affect all 81 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place the call light within reach of residents, and failed to follow recommendations for getting resident up as desired for 5 of 8 residents (R20, R44, R54, R72, R175) reviewed for accommodation of needs in the sample of 51.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate injuries of unknown origin, and a sexual abuse allegation for 4 of 6 residents (R24, R36, R51, R66) reviewed for abuse in the sample of 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with grooming and hygiene, and failed to provide oral care to dependent residents for 8 of 18 residents (R5, R24, R29, R30, R43, R51, R53, R63) reviewed for Activities of Daily Living (ADL) in the sample of 51.

Inspectors wrote4. R5's admission Record, print date of 6/29/22, documents R5 was admitted on [DATE], and has a Diagnosis of Dementia with Behavioral Disturbances. R5's MDS, dated [DATE], documents R5 is severely cognitively impaired, requires extensive assistance of 2 staff members for transfer, extensive assistance from 1 staff member for bed mobility, dressing and toileting, supervision for walking in room, eating and is totally dependent on one staff member for personal hygiene. This MDS also documents R5 is frequently incontinent of urine. R5's Care Plan, dated 6/5/21, documents, The resident has bladder incontinence r/t (related to) Alzheimer's Disease. Check the resident q (every) 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episode. On 6/27/22 at 9:00 AM, R5 was assisted to his room by V37, CNA; the back of R5's pants are wet. [...]

Inspectors wroteBased on obervation, interview, and record review, the facility failed to provide structured and meaningful activities for 6 of 6 residents (R5, R15, R29, R40, R71) reviewed for Dementia care in the sample of 51.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to ensure foods were served at safe and palatable temperatures.

Inspectors wroteBased on interview and record review, the facility failed to immediately report allegations of abuse and injuries of unknown origin to the Administrator and to the Illinois Department of Public Health (IDPH) for 3 of 6 residents (R24, R26, R66) reviewed for abuse in the sample of 51.