Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sanford Hillsboro Care Center during CMS and state inspections, most recent first.
A resident receiving Lasix and Tramadol did not have their care plan updated to identify problems or interventions related to these medications. Facility policy requires care plans to be modified to reflect current care needs, but this was not done, as confirmed by administrative staff.
A medication aide prepared medications for a resident and later handed them to a nurse, who then administered them, contrary to facility policy and professional standards requiring staff to administer only medications they have personally prepared. The resident's medication administration record reflected the aide as the person who administered the medications, despite the nurse actually giving them.
A resident with a history of frequent falls and weakness experienced a fall during a transfer from a tub chair to a wheelchair when staff failed to lock the tub chair brakes as required by facility policy. The tub chair rolled back, causing the resident to fall, as confirmed by interviews and documentation.
A resident suffered burns from hot coffee due to the facility's failure to monitor beverage temperatures, with machines dispensing liquids at up to 181°F. Despite instructions to cool beverages, staff did not routinely check temperatures, leading to an Immediate Jeopardy situation. Additionally, the resident experienced an unsafe transfer with a mechanical lift, highlighting inadequate assistance and improper use of assistive devices.
A facility failed to accurately communicate a resident's code status, leading to a potential misinterpretation of their advance directives. The resident's medical record indicated a preference for chest compressions but no intubation, yet a red dot on their chart suggested a DNR status. An administrative nurse confirmed this discrepancy, which could mislead staff during a medical emergency.
A facility failed to provide a written notice of transfer to a resident or their representative, as required by their policy. The deficiency was identified during a review of the facility's 'Transfer to Hospital Guide,' which mandates timely notification and documentation in the medical record. A review of a resident's medical record revealed a lack of documentation for a hospital transfer, and an administrative staff member confirmed the failure to provide the necessary written notice.
A nurse failed to prime a Humalog insulin pen before administering it to a resident, contrary to the facility's policy. The policy requires priming by turning the dosage knob to '2' units and ensuring a drop of insulin appears. An administrative staff member confirmed the expectation for staff to follow this procedure.
The facility failed to follow infection control standards during care for three residents, involving improper hand hygiene and glove use. A CNA and a nurse did not perform hand hygiene after removing gloves during perineal care, dressing changes, and insulin administration, potentially spreading infections. An administrative nurse confirmed the expectation for staff to adhere to infection control guidelines.
The facility did not post daily staffing data for nine out of fifteen days, affecting six day shifts, six evening shifts, and one night shift. This omission was confirmed by an administrative staff member, hindering transparency about staffing levels for residents and visitors.
Failure to Update Care Plan for Resident Receiving Diuretic and Opioid
Penalty
Summary
The facility failed to review and revise the care plan to reflect the current status for one resident who was receiving unnecessary medications. Record review showed that the resident had physician's orders for Lasix, a diuretic, and Tramadol, an opioid pain medication, both administered twice daily. However, the resident's care plan did not identify problems or interventions related to the use of these medications. This omission was confirmed by an administrative staff member, who acknowledged that the care plan had not been updated as required by facility policy, which states that the plan of care should be modified to reflect the care currently required or provided for the resident.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
A medication aide prepared a cup of medications and applesauce for a resident and placed them in the medication cart drawer. Later, the aide handed these prepared medications to a nurse, who confirmed the resident's name and then administered the medications to the resident. The aide acknowledged that she had prepared the medications earlier that morning and had attempted to administer them twice before handing them to the nurse. The facility's policy and professional nursing standards both require that staff only administer medications they have personally prepared, and not those prepared by another individual. Review of the resident's electronic medication administration record showed that the medications were documented as administered by the medication aide, despite the nurse actually giving them. An administrative staff member confirmed that the facility's expectation is for medication aides and nurses to administer only those medications they have personally prepared. This sequence of actions did not follow the facility's policy or professional standards for medication administration.
Failure to Lock Tub Chair Brakes During Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to properly utilize assistive devices necessary to prevent accidents for a resident with a history of frequent falls and an ADL deficit related to weakness. The facility's policies required staff to lock brakes on wheelchairs and tub chairs during transfers, and to ensure safe and proper use of assistive devices. However, during a transfer from a tub chair to a wheelchair in the shower room, the brakes on the tub chair were not locked. As a result, the tub chair rolled back while the resident was being assisted to stand, causing the resident to fall onto his right side. The incident was confirmed through resident and staff interviews, as well as a review of the medical record and facility policies. The event review documented that the CNA did not lock the tub chair brakes, directly leading to the fall.
Failure to Prevent Burn Hazards and Ensure Safe Transfers
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, resulting in a burn injury to a resident. During the on-site recertification survey, it was observed that the coffee and hot water machines dispensed liquids at dangerously high temperatures, reaching up to 181 degrees Fahrenheit. Despite posted instructions to add ice or wait three minutes before serving, staff did not routinely monitor or adjust the temperatures, leading to a resident spilling hot coffee and sustaining burns on her thighs and labia. The resident involved in the incident had a history of falling and was diagnosed with dementia. On the day of the incident, she was sitting in the dining room when she spilled hot coffee onto her lap. Immediate first aid was administered, and the resident was treated for first and second-degree burns. The survey team identified an Immediate Jeopardy situation due to the lack of temperature monitoring and the potential risk of serious burns to all residents. Additionally, the facility failed to provide adequate assistance during a mechanical lift transfer for the same resident. The resident, who required assistance due to her medical condition, was observed having difficulty holding onto the lift handles, resulting in an improper transfer. The harness sling slid up her back, causing her elbows to bow outward, indicating improper use of the assistive device. This placed the resident at risk for accidents and injury during transfers.
Removal Plan
- Disconnected power to coffee machines, coffee and hot water with temperatures at or below 150 degrees were made available in carafes
- Implement focus audit to monitor coffee and hot water temperatures in carafes
- Education was provided to dietary and nursing staff
- Message sent to nursing staff to review the policy related to hot liquids
Inaccurate Communication of Resident's Code Status
Penalty
Summary
The facility failed to ensure that all forms of communication accurately reflected a resident's code level status, which is crucial for honoring the resident's advance directives. Specifically, for one resident, the medical record indicated a preference for Code Level 1, which included chest compressions but no intubation. However, a red dot on the resident's chart, which staff interpreted as a do not resuscitate (DNR) order, contradicted this directive. An administrative nurse confirmed that the red dot would lead staff to mistakenly identify the resident as DNR, highlighting a discrepancy between the resident's documented wishes and the facility's communication system. This inconsistency limited the facility's ability to convey the resident's choices accurately in a medical emergency.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their representative, as required by their policy. This deficiency was identified during a review of the facility's policy titled 'Transfer to Hospital Guide,' which mandates timely notification to the resident, family member, or legal representative, with documentation in the medical record. The review of the medical record for a resident who was transferred to the hospital revealed a lack of documentation indicating that a written transfer notice was provided. An administrative staff member confirmed the failure to provide the necessary written notice during an interview.
Failure to Prime Insulin Pen as per Policy
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of insulin for a resident. During an observation, a nurse prepared a Humalog insulin pen for a resident without priming it as required by the facility's policy. The policy, revised in December 2023, mandates that the insulin pen should be primed by turning the dosage knob to '2' units and pressing the button until a drop of insulin appears. However, the nurse directly dialed the pen to the prescribed units without priming it, which could lead to an inaccurate dose being administered. An administrative staff member confirmed that it is expected for staff to prime insulin pens according to the policy. This oversight was identified during a review of the facility's policy on insulin administration and through direct observation of the nurse's actions.
Infection Control Breach in Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to adhere to infection control standards during the care of three residents, specifically in the areas of hand hygiene and glove use. A certified nurse aide assisted a resident with perineal care and other tasks without performing hand hygiene after removing gloves, which is a breach of the facility's hand hygiene policy. Similarly, a nurse conducted perineal care, dressing changes, and applied ointment to another resident without changing gloves or performing hand hygiene between tasks, further violating infection control protocols. Additionally, the same nurse failed to remove gloves and perform hand hygiene after scanning a resident's blood glucose levels and before administering insulin. The nurse continued to use the same gloves while handling equipment and typing on a computer, which could potentially spread infections. These actions were observed and documented, and an administrative nurse confirmed that staff are expected to follow infection control guidelines, indicating a lapse in adherence to established procedures.
Failure to Post Daily Staffing Data
Penalty
Summary
The facility failed to post daily staffing data for all shifts on nine out of fifteen days reviewed, specifically from May 14 to May 28, 2024. This deficiency was identified through a review of daily staffing information and confirmed during an interview with an administrative staff member. The missing data included the number of staff working on six day shifts, six evening shifts, and one night shift, which prevented residents and visitors from being informed about the staffing levels for each shift.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Halstad Living Center | 11.6 mi | ★★★★★ | 6 | 0 |
| Luther Memorial Home | 13.8 mi | ★★★★★ | 3 | 0 |
| Hatton Prairie Village | 24.5 mi | ★★★★★ | 4 | 0 |
| Benedictine Care Community | 25.7 mi | ★★★★★ | 31 | 1 |
| Northwood Deaconess Health Cnt | 33.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.