Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Foothill Acres Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
Kitchen sanitation was not maintained consistently, as surveyors found improperly labeled and stored food in the kitchen and unit pantries, including sealed food without a use-by date, an open bag of frozen food left exposed, an unlabeled staff drink in a resident freezer, expired juice in a pantry refrigerator, and resident-labeled ice cream without a date. Surveyors also observed buildup on an ice machine, and the maintenance log showed it had not been cleaned since the prior month.
PRN pain management was not appropriately documented or followed for a resident with severe cognitive impairment, a stage 4 sacral pressure ulcer, Parkinson’s disease, and other serious diagnoses. The MAR showed Tramadol 50 mg was given multiple times when the recorded pain score was below the ordered threshold of 4-10, and an RN/UM acknowledged chronic non-compliance with the physician’s pain parameters.
Failure to consistently implement ASP monitoring: the facility did not use standardized infection surveillance criteria to determine whether antibiotics were appropriate for 3 residents reviewed. A resident with a toe ulcer, a resident with bronchitis, and a resident with a tooth infection were each started on antibiotics, but there was no documented evidence that McGeer or Loeb criteria were applied. The IP said criteria were reviewed but not documented, while the DON confirmed the IP should complete and document the McGeer checklist.
A resident with muscle weakness, difficulty walking, and intact cognition was observed tearful after a PT spoke to him/her in a loud, firm, and demeaning tone, including a remark that “some people would disagree” with the resident being “stupid.” The resident said the PT was always mean and was upset about not being able to go home on pass. The PT later admitted the tone was talking down to the resident and not appropriate, and the DOR, DON, and LNHA confirmed the interaction was not professional or respectful.
The facility failed to provide written notice to residents with PNA balances approaching the SSI resource limit. Five residents had balances between about $1,846 and $2,385, and the BOM said there was no documentation of notification even though residents should be alerted when balances reached about $1,800. The LNHA and DON acknowledged that letters should have been sent, and one resident remained over the threshold after refusing to spend down funds.
A RN failed to follow infection control and wound care standards during treatment of a resident with a Stage 4 sacral PU and intact cognition. The RN removed a soiled dressing but continued care with the same gloves, used a multi-use Dakin’s bottle without designating it resident-specific, applied an unlabeled foam dressing, and then wrote the date, time, and initials on the dressing after it was already in place. The RN, RN/UM, and DON all acknowledged the proper steps for glove changes, hand hygiene, dressing labeling, and handling of multi-use supplies.
A resident was not given the opportunity to review her care plan or medication list during a quarterly care conference, leading to unmet needs and preferences. Despite being cognitively intact, the resident was unaware of her care plan and expressed dissatisfaction with the conference, which did not address her concerns. The unit manager acknowledged the oversight, as the care plan had not been updated since its initiation.
A resident in a LTC facility, who was cognitively intact but physically dependent, did not receive timely incontinence care, resulting in her being left in a wet brief from the previous night until late the next day. This delay caused her to miss activities and appointments, and she expressed frustration about being the last to receive assistance. Observations noted a small abrasion on her skin, and interviews with CNAs confirmed the delays in care, indicating a failure to follow the resident's care plan effectively.
Kitchen Food Storage and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food-borne illness. During observation in the kitchen, the Food Service Director stated that food in refrigerators and freezers should be sealed in air-tight wrap and labeled with a use-by date, and that dietary staff were responsible for maintaining pantry inventory to ensure there were no expired items. In the walk-in freezer, surveyors found a two-inch steam pan of chicken parmesan that was sealed but had no prepared or use-by date, and a 10.5 oz bag of vegan chicken nuggets that was open and not resealed, leaving the contents exposed. The Regional Food Service Director discarded both items. In the 200 Unit pantry, surveyors observed an unlabeled styrofoam cup in the freezer; when the LPN/UM removed it to look inside, an Activities Aide took the cup and began drinking from it, and stated the cup belonged to him. The LPN/UM stated staff should not store their food or drinks in resident refrigerators. In the same pantry refrigerator, a 15.2 oz bottle of juice with an expiration date of 3/20/26 was found expired and discarded. In the 400 Unit pantry, surveyors observed a previously opened container of ice cream labeled with a resident's name and room number but without the date it was placed in the freezer or a use-by date, and a white substance buildup along the ice dispenser on the ice machine. The RN/UM stated the ice machine should be cleaned daily, and the facility's maintenance log showed it was last cleaned on 3/24/26.
PRN Pain Medication Given Outside Ordered Pain Parameters
Penalty
Summary
Safe, appropriate pain management was not provided for a resident who had diagnoses including a stage 4 sacral pressure ulcer, Parkinson’s disease, dementia, dysphagia, and adult failure to thrive. The resident’s quarterly MDS indicated severe cognitive impairment, and the care plan included a pain focus with interventions to administer pain medications per physician orders. The physician order for Tramadol 50 mg every 6 hours as needed for pain score 4-10 was not followed as documented in the MARs. Review of the MAR showed Tramadol was administered on multiple occasions when the documented pain scores were 0, 1, 2, or 3, including entries in December 2025, January 2026, February 2026, April 2026, and May 2026. During interview, the RN/UM stated there was one nurse who was chronically non-compliant with following the physician orders for pain level parameters and that the issue had been addressed with the nurse on multiple occasions. The facility’s pain management policy stated that the nurse assesses the resident for signs and symptoms of pain using the pain assessment form for cognitively impaired residents or the pain assessment record.
Failure to Consistently Implement Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to consistently implement an Antibiotic Stewardship Program and did not use standardized infection surveillance criteria to determine whether antibiotic use was appropriate for residents started on antibiotics. This deficiency was identified in 3 of 6 residents reviewed for antibiotic use. A review of the Infection Control Case List in the EMR for 5/2026 showed that Resident #61 had a right toe ulcer with an onset date of 5/18/2026 and was started on an antibiotic the same day, but there was no evidence that standardized infection surveillance criteria were used to determine the appropriateness of the antibiotic prescribed. The same issue was identified for Resident #74, whose Infection Control Case List showed bronchitis with an onset date of 5/8/2026 and an antibiotic started on that date, and for Resident #154, whose Infection Control Case List showed a tooth infection with an onset date of 5/19/2026 and an antibiotic started on that date. The Infection Preventionist stated residents must meet criteria before antibiotics are initiated and said the facility used both Loeb Criteria and McGeer Criteria, but there was no formal checklist and her review was not documented. The DON stated the facility used McGeer Criteria for antibiotic stewardship and confirmed the IP should complete and document the McGeer checklist rather than only reviewing the criteria. The CPC reported the facility used McGeer Criteria and that she reviewed them monthly through progress notes, laboratory results, and other clinical documentation.
Resident Not Treated with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with respect and dignity in a manner that promotes quality of life. During an initial tour, a surveyor overheard a male voice speaking in a loud, firm tone to the resident, asking, “Are we on the same page? Do you understand what I’m saying?” The resident replied, “Yes, I understand, I’m not stupid,” and the male voice responded, “Well, some people would disagree with that.” When the surveyor approached the room, the man left and was wearing a sweatshirt with the facility’s name on it. The resident was sitting up in bed, tearful, and identified the man as a PT, then repeated the conversation the surveyor had overheard. The resident stated being upset about not being physically able to go home on pass and said the PT was always mean to him/her. The resident’s record showed diagnoses including muscle weakness and difficulty walking. The quarterly MDS indicated a BIMS score of 13 out of 15, showing intact cognition. The comprehensive care plan addressed the resident’s potential to be verbally aggressive related to emotional feelings and included interventions to assess understanding, allow time to express feelings, and, when agitated, intervene before escalation, guide away from the source of distress, engage calmly, and walk away and reapproach later if needed. Facility staff interviewed by the surveyor stated the resident could be verbally aggressive at times, but also emphasized the importance of making the resident feel safe and speaking respectfully. The PT later entered the room and apologized, stating he should not have spoken that way. When interviewed, the PT acknowledged the resident said he did not say nice things and admitted that his tone was talking down to the resident and was not appropriate. The DOR, DON, and LNHA each confirmed that the interaction was not professional or respectful and stated staff should respond respectfully, step away if needed, and reapproach later rather than fight back with the resident. The PT job description required professional relationships and communication in a professional manner, and the facility’s Resident Rights policy stated residents, visitors, and staff will be treated with dignity and respect and that residents have the right to be treated with courtesy, consideration, and respect.
Failure to Notify Residents of PNA Balances Approaching SSI Limit
Penalty
Summary
The facility failed to ensure that residents with Personal Needs Accounts (PNA) received written notification when their balances were approaching the limit that could affect Medicaid or SSI eligibility. A review of the facility’s Patient Fund Balances on 5/15/26 showed that 5 residents had PNA balances ranging from $1,846.70 to $2,385.22, including Resident #33, #111, #122, #163, and #164. The Business Office Manager stated that statements were given quarterly and residents could request them at any time, but there was no documentation showing written notification when balances neared the $2,000 limit. She also stated that some residents remained over that amount and that residents should be notified when their PNA reached $1,800.00. During interviews, the LNHA stated that a letter should have been sent to notify the resident or representative because the resident could lose Medicaid. The DON later stated that after surveyor inquiry the facility spoke with the residents and reduced their balances except for Resident #122, who refused to spend down and whose sister made purchases without providing all receipts. The DON stated that another letter was sent because Resident #122 remained above $1,800.00. The facility’s PNA policy dated 5/21/26 stated that residents receiving Medicaid benefits would be notified when the account reached $200 less than the SSI resource limit for one person and that reaching the SSI resource limit could result in loss of Medicaid or SSI eligibility.
Infection Control Lapses During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to maintain infection control practices and professional standards during a pressure ulcer treatment for a resident with multiple sclerosis who had an intact cognition score of 14 out of 15 and a Stage 4 sacral pressure ulcer present on admission. The resident’s care plan directed treatment per physician orders, and the active order required the sacrum to be packed with Dakin’s moist gauze and covered with foam every day and evening shift. During the wound care treatment, the RN performed hand hygiene, donned gloves, cleaned the overbed table, and gathered supplies including a multi-use bottle of quarter-strength Dakin’s solution. After entering the room, the RN removed the old soiled dressing and disposed of it, but then continued the treatment with the same gloves by cleaning the wound bed with saline-soaked gauze, drying the wound, and measuring the wound before removing gloves and using ABHR. The RN then packed the wound with Dakin’s-soaked gauze and covered it with an undated and unlabeled foam dressing, and after the dressing was already applied, wrote the date, time, and initials on the middle of the foam dressing. After the treatment, the RN wiped down the overbed table and the multi-use Dakin’s bottle but did not designate the bottle as resident-specific before returning it to the treatment cart. The RN later acknowledged she should have removed her gloves and performed hand hygiene after discarding the soiled dressing, should have labeled the foam dressing before applying it, and that multi-use bottles should stay in the resident’s room for infection control purposes. The RN/UM and DON both stated that gloves and hand hygiene should be changed after removing the soiled dressing, that dressings should be dated and initialed before application, and that multi-use bottles should not be brought into the resident’s room unless designated for that resident.
Resident's Care Plan Not Reviewed or Updated During Conference
Penalty
Summary
The facility failed to ensure that a resident, identified as R68, was provided with the opportunity to review her care plan, medication list, and express her concerns during a quarterly care conference. The facility's policy requires an interdisciplinary approach to care planning, involving the resident and/or family in discussions to address individual needs. However, during the quarterly care conference, R68 was not made aware that it was her care conference, and her concerns were not adequately addressed, leading to a lack of updates to her care plan. R68, who was cognitively intact with a BIMS score of 15, expressed dissatisfaction with the care conference, stating it was filled with arguments and did not address her needs. She was unaware of her care plan and expressed a desire to be involved in discussions about her care and medications. R68 highlighted issues such as being on multiple bowel regimen medications without explanation, leading to diarrhea, and her preference for not being changed during certain hours was not respected, resulting in prolonged periods in a wet diaper. The unit manager acknowledged that the medication list and care plan should have been reviewed during the conference, and the care plan should have been updated to reflect R68's needs. The care plan had not been revised since its initiation, and the unit manager confirmed that it would be revised to address R68's needs. This oversight resulted in care not being tailored to R68's preferences and needs, as her care plan was not updated accordingly.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R68, who was cognitively intact but physically dependent on staff for assistance with activities of daily living (ADLs). R68 was admitted to the facility in April 2021 and required substantial to maximal assistance for bed mobility, transfers, dressing, and toileting. The resident's care plan indicated a preference for being washed and changed at 10 AM, but she often refused care during the night shift and preferred not to be disturbed between 9 PM and 9 AM. On multiple occasions, R68 was left in a wet brief from the previous night until late the following morning or early afternoon. On one occasion, she was not changed until 1:17 PM, and on another, not until 11:46 AM. This delay in care resulted in R68 missing activities and doctor's appointments, and she expressed frustration about being the last resident to receive assistance. Observations revealed that R68 had a small abrasion near her buttock and thigh area, and she reported experiencing pain when wet. Interviews with CNAs confirmed the delays in providing care, and it was noted that R68's care plan was not being followed effectively. The resident's skin condition was monitored, and a barrier cream was applied to prevent further skin breakdown. Despite the resident's preferences and care plan instructions, the facility's failure to provide timely incontinence care placed R68 at risk for skin issues and impacted her daily routine and participation in activities.
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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 Hillsborough
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgeway Care And Rehab Center At Hillsborough | 2.8 mi | ★★★★★ | 9 | 0 |
| Waterfront Rehabilitation And Healthcare Center | 6.2 mi | ★★★★★ | 13 | 0 |
| Bridgeway Care And Rehab Center At Bridgewater | 6.2 mi | ★★★★★ | 2 | 0 |
| Stonebridge At Montgomery Health Care Center | 6.7 mi | ★★★★★ | 0 | 0 |
| The Arbor At Laurel Circle | 7.4 mi | ★★★★★ | 8 | 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 October 2026) and official state health department websites.