Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Hillsboro Health And Rehab Llc during CMS and state inspections, most recent first.
Unsafe food storage and sanitation practices were observed in the kitchen and resident refrigerators. Surveyors found dirty ceiling vents above food prep areas, food boxes stored on the freezer floor, an open thickener container without an open date, no thermometer in the milk cooler, and no documented sanitation testing for the low-temp dishwasher. In resident refrigerators, staff food was mixed with resident food, several open resident food items lacked open dates, and another refrigerator had dried debris and ice buildup; the DON and an LPN verified these conditions.
Therapeutic diets were not followed for multiple residents with DM, COPD, CKD, dementia, and other diagnoses. Meal tickets and the therapeutic diet spreadsheet called for specific items such as consistent carbohydrate portions, diet syrup, low sodium fried egg sandwiches, and no added salt diets, but staff served incorrect portions, regular syrup, biscuit and gravy, or substituted items not listed. The DM and RD verified the foods served did not match the ordered diets, and the facility had no defined measurement for a large portion.
Failure to Follow Infection Control Practices During Medication Pass and Incontinence Care: An RN administered meds to three residents without hand hygiene and used bare hands to place one resident’s medication in a cup. During incontinence care, a CNA used the same gloves throughout care and applied a clean brief without changing gloves or performing hand hygiene. The residents involved had significant cognitive and functional impairment, and one resident was always incontinent of bladder and bowel.
Failure to maintain hot water temperatures in the 100-hallway affected one cognitively intact resident and potentially all residents on that unit. The resident reported no hot water in the bathroom for months and was using tubs of warm water for bathing, while direct testing showed the bathroom water did not get warm after running for five minutes. The MDS noted the resident had DM2, generalized weakness, anxiety, and HTN. The MDS confirmed the hallway had no functional hot water, despite replacement of two water heaters and identification of a busted water line; most tested bathrooms measured only 63 to 67 degrees F.
Medications were not properly labeled for two residents. The DON observed open insulin and diabetes injection pens on medication carts with no open date or expiration date documented, and a vial of tuberculin in the medication refrigerator with an open date that was recorded. The residents involved had diabetes and other chronic conditions, and one had intact cognition while the other had moderate cognitive impairment.
A resident with complex medical needs and limited self-care abilities was discharged from the facility to a homeless shelter without adequate notice, preparation, or discharge planning. The resident did not receive necessary diabetic teaching, lacked essential supplies, and was not provided with assistance to secure income or housing. The homeless shelter lacked medical staff and could only provide temporary accommodation, and the resident was unaware of the discharge until the day it occurred. Facility staff did not notify the Ombudsman or provide proper documentation of the discharge process.
A resident with multiple chronic conditions, who was cognitively intact, was discharged without receiving the required notice of discharge, and the Ombudsman was not notified prior to the discharge. Staff confirmed that no discharge notice was provided because the resident was agreeable to leave, and the Ombudsman had not been informed.
The facility did not have an RN on duty for at least eight hours on multiple days, as confirmed by staffing records and interviews with the DON and administrator. This affected all 74 residents in the facility.
Unsafe Food Storage and Sanitation Practices
Penalty
Summary
Food was not stored, prepared, and served in a safe and sanitary manner in the kitchen and resident refrigerators. During a kitchen tour, surveyors observed two ceiling vents directly above food preparation areas and the stove with a visible buildup of gray debris, three stacks of unopened food boxes stored directly on the freezer floor, an open thickener container with no open date, and no thermometer inside the milk cooler. Review of the dishwasher temperature and sanitation log showed no recorded sanitation testing results for May 2026, and the Dietary Manager verified the facility had changed from a high-temperature dishwasher to a low-temperature dishwasher that required sanitation testing, but no testing had been documented during the dishwasher cycles after each meal. In the 400-unit resident refrigerator, surveyors observed three containers of staff food and six open resident food items with no open dates, despite a sign stating all items must have a date, resident name, and item name. The LPN verified the refrigerator should be used only for resident food items and that open foods should have an open date. In the 200-unit resident refrigerator, the DON observed dried red debris on the bottom shelf and about one inch of ice buildup around the top and sides of the freezer, and stated the bottom shelf needed cleaning and the freezer needed defrosting. Facility policies reviewed addressed sanitation, food storage, and visitor-brought foods, including labeling and discard requirements.
Therapeutic diets not followed for multiple residents
Penalty
Summary
The facility failed to provide and serve foods as planned by the Registered Dietitian for four residents reviewed. The report states that the facility did not follow the therapeutic diet meal spreadsheet and meal tickets for residents ordered to receive consistent carbohydrate, no added salt, and related diet orders. The dietary manager verified that there was no defined measurement for what constituted a large portion on the meal spreadsheet or in a policy, and the cook was expected to follow the portions listed on the residents’ meal tickets and therapeutic diet spreadsheet. Resident #1 had diagnoses including diabetes, COPD, morbid obesity, and respiratory failure, and was ordered a consistent carbohydrate large portion diet. On one breakfast observation, the resident received two servings of egg and two servings of biscuit with sausage gravy, which the dietary manager verified should not have been served on that diet. On another breakfast observation, the resident received waffles without syrup or butter, and the dietary manager verified the resident should have received diet syrup and butter as listed on the meal ticket and therapeutic diet spreadsheet. Resident #2 had diagnoses including COPD, anxiety disorder, kidney failure, CVA, heart failure, and diabetes, and was also ordered a consistent carbohydrate large portion diet. The resident’s meal ticket called for one biscuit with sausage gravy and one egg, but the observation showed two servings of biscuit with sausage gravy and two servings of egg; the dietary manager verified this was not appropriate for the ordered diet. The resident also received regular syrup with waffles when diet syrup was listed on the meal ticket and spreadsheet. Resident #57 had dementia, COPD, hypertensive heart disease, diabetes, and chronic kidney disease, and was ordered a no added salt diet with house supplement three times daily. The meal ticket called for a low sodium fried egg sandwich, but the resident was observed receiving a sliced biscuit with scrambled eggs in between the biscuit slices. Staff verified the resident should have received a fried egg sandwich made with one large fried pasteurized egg between two slices of white toasted bread, and one staff member stated there were no pasteurized eggs available and was unaware of the diet requirement. Resident #4 had dementia, diabetes mellitus type 2, psychosis, osteoporosis, hypertension, and hypothyroidism, and was ordered a no added salt and consistent controlled carbohydrate diet. The meal ticket called for a low sodium fried egg sandwich, but the resident was observed receiving biscuit and gravy, with no substitute or preference documented on the tray ticket. The RD verified the foods served should have matched the meal ticket and therapeutic diet spreadsheet, and the facility policy stated residents would not receive extra portions that were not part of the diet.
Failure to Follow Infection Control Practices During Medication Pass and Incontinence Care
Penalty
Summary
The facility failed to ensure infection control standards were implemented during medication administration and incontinence care. During observation of medication pass, RN #402 administered medications to Resident #80, Resident #13, and Resident #62 without performing hand hygiene. The nurse was observed leaving to help another staff member and then returning to prepare and administer Resident #80's medications without using hand hygiene. RN #402 was also observed using bare hands to place Resident #62's medication into the medication cup. During interview, RN #402 confirmed there was no hand hygiene between administering medications to the three residents and confirmed using bare hands to place Resident #62's medication in the cup. The facility also failed to follow glove and hand hygiene practices during incontinence care for Resident #51, who had diagnoses including acute muscle weakness, dysphagia, and displaced intertrochanteric fracture of the left femur, and was dependent for all ADLs and always incontinent of bladder and bowel. During observation, CNA #210 did not change gloves after incontinence care and used the same gloves to apply a clean brief to the resident. The CNA did not change gloves from the beginning to the end of care. NS #410 confirmed the CNA did not change gloves throughout the care. Facility policy for administering medications required staff to follow infection control procedures, and the perineal care policy required staff to discard gloves, perform hand hygiene, and apply clean gloves before putting on a clean brief.
Failure to Maintain Hot Water Temperatures
Penalty
Summary
The facility failed to maintain comfortable water temperatures in the 100-hallway, affecting Resident #10 and potentially all 22 residents on that hallway. Resident #10 was admitted with diagnoses including type II diabetes mellitus, generalized muscle weakness, adjustment disorder with anxiety, and essential hypertension, and her MDS indicated she was cognitively intact. During an interview, she stated she had not had hot water in her bathroom since February and had been receiving tubs of warm water in the morning and evening to wash with instead. When the hot water was turned on in her bathroom and left running for five minutes, it did not get warm. Maintenance Director #308 confirmed that residents on the 100-hallway had not had hot water in their rooms since March 2026. He stated that two hot water heaters on the 100-hallway were replaced in March but did not resolve the problem. He further stated that a busted water line was discovered and needed repair for hot water to function on the hallway, and that he had submitted the repair bid to corporate office around April 2026, but it had not yet been approved. Observation of the 100-hallway bathrooms showed that seven of nine bathrooms had hot water temperatures in the 63 to 67 degree Fahrenheit range.
Medications and Immunization Storage Not Properly Labeled
Penalty
Summary
Medications were not labeled in accordance with accepted professional principles. During review of Resident #39, who had diagnoses including type 2 diabetes, hypothyroidism, and an unspecified fracture of the lower right leg, the resident was found to have orders for Fiasp FlexTouch insulin and Trulicity injections. Resident #39 had intact cognition with a BIMS score of 14 and was dependent on staff for all ADLs. During observation of the 100-hall medication cart with the DON, one Fiasp FlexTouch pen-injector and one Trulicity auto-injector for this resident were both open but had no open date and no expiration date documented. A similar labeling issue was found for Resident #4, who had diagnoses including type 2 diabetes mellitus with hyperglycemia, GERD, and hypertension. Resident #4 had a physician order for Lantus Solostar insulin and was assessed with moderate cognition, with a BIMS score of 8, and required moderate assistance with ADLs. Observation of the 200-hall medication cart with the DON revealed one Lantus Solostar pen-injector that was open with no open date or expiration date. In addition, observation of the 400-hall medication room revealed one vial of tuberculin in the medication refrigerator with an open date of 02/11/26. The DON verified these findings, and the facility policy stated that when opening a multi-dose container, the date shall be recorded on the container.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
A deficiency occurred when a resident with complex medical needs, including type 1 diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term insulin use, was discharged from the facility to a homeless shelter after residing there for over 22 years. The resident had a history of impaired vision, required supervision with insulin administration, and had documented deficits in adaptive functioning and executive skills. Despite these needs, there was no evidence of discharge planning, diabetic teaching, or preparation for self-care documented in the medical record prior to discharge. The resident was not provided with sufficient notice or preparation for the discharge, and there was no documentation of attempts to secure income, alternative housing, or necessary identification documents. The homeless shelter to which the resident was discharged did not have medically trained staff, only allowed a maximum 90-day stay, and had recently lost funding for programs that could assist with housing. Upon arrival, the resident lacked essential supplies such as insulin needles, which were only provided days later. The shelter staff and executive director expressed concerns that the resident lacked the life skills, income, and resources to care for himself and that the shelter was not an appropriate or safe discharge location. The resident missed a scheduled follow-up medical appointment due to lack of transportation arrangements, and interviews confirmed that he was unaware of the discharge plan until the day of transfer. Facility staff, including the DON and social services, confirmed that no discharge notice was provided to the resident or the Ombudsman, and that the discharge was prompted by insurance denial of payment for continued stay. Multiple interviews with staff, the resident, and external parties revealed that the discharge process was abrupt, lacked proper planning, and failed to ensure the resident's needs and preferences were met. There was no evidence of interdisciplinary team involvement or adequate preparation for the resident's transition to the community.
Removal Plan
- The Administrator immediately reviewed the last 30 days of discharges to ensure safe discharges occurred. No other areas of concern were noted.
- Follow up contact was made to Resident #83, #84, #85, #86, #87, and #88 who were discharged in the last 30 days. No concerns regarding discharge and no additional needs were identified by each resident.
- The Administrator immediately reviewed the pending discharges for Resident #16 and Resident #26 to ensure safe discharges plans with no other areas of concern noted.
- Social Services Director #180 and/or designee will notify the Ombudsman of the date the discharge notice is given.
- An in-service regarding the discharge process was completed by the Administrator with Social Services Director #180 that addressed the following: Except as specified below, a resident, and/or his or her representative will be given advance notice of an impending transfer or discharge from our facility: The transfer is necessary for the residents' welfare and the residents' needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the residents no longer need the services provided by the facility. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. The health of individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. An immediate transfer or discharge is required by the residents' urgent medical needs. The resident is transferred for other than medical reasons. The resident has not resided in the facility for thirty days; and/or the facility ceases operating. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The reason for the transfer or discharge. The effective date of the transfer or discharge. The location to which the resident is being transferred or discharged. The name, address, and telephone number of the state long-term care ombudsman. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. The facility will not transfer or discharge the resident while an appeal for discharge is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility.
- A Quality Assurance and Performance Improvement (QAPI) meeting with the Administrator, Director of Nursing, Medical Director #275 and SSD #180 was held to review the discharge policy and procedure. No changes were made to the discharge policy and procedure at this time.
- The Facility Administrator was in-serviced by President of Operations #375 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge.
- A full Intradisciplinary Team (IDT) meeting was held which included the Administrator, DON, SSD #180, Business Office Manager (BOM) #152, Assistant Director of Nursing (ADON) #166, and Activity Director #128 regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge that addressed the following: Except as specified below, a resident, and/or his or her representative will be given advance notice of an impending transfer or discharge from our facility: The transfer is necessary for the residents' welfare and the residents' needs cannot be met in the facility. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the residents no longer need the services provided by the facility. The safety of individuals in the facility is endangered due to clinical or behavioral status of the residents. The health of individuals in the facility would otherwise be endangered. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. An immediate transfer or discharge is required by the residents' urgent medical needs. The resident is transferred for other than medical reasons. The resident has not resided in the facility for thirty days; and/or the facility ceases operating. The resident, and/or representative will be provided with the following information: The facility will send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The reason for the transfer or discharge. The effective date of the transfer or discharge. The location to which the resident is being transferred or discharged. The name, address, and telephone number of the state long-term care ombudsman. The name, address, and telephone number of each individual or agency responsible and the name, address, and telephone number of the state department agency that has been designated to handle appeals of transfers and discharge notices. The facility will not transfer or discharge the resident while an appeal for discharge is pending, unless the failure to discharge or transfer will endanger the health or safety of the resident or other individuals in the facility.
- A full house education was done by the Administrator and DON regarding the discharge process, required notifications, required notices, and preparation and orientation for discharge.
- Pending discharges will be discussed in the Stand-up Meeting daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday, with the IDT to ensure safe discharge plans and teaching or other needs. The IDT includes the following: Administrator, DON, ADON #166, BOM #152, SSD #180, and Activity Director #128. In the absence of one of these team members the other team members will act on their behalf.
- The Administrator, DON, or SSD #180 will notify Medical Director #275 of any pending discharge plans daily Monday-Friday on business days, discharges pending for the weekends or holidays will be covered in the meeting Monday-Friday by Friday.
- Pending discharge plans will be reviewed by the Administrator and/or designee and Director of Nursing and/or designee in Stand-up Meeting at least 3 times weekly for 6 weeks to ensure safe discharge plans have been made.
Failure to Provide Timely Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide timely and appropriate notice of discharge to a resident and the Ombudsman. Record review showed that a resident, admitted in May 2003 with diagnoses including type one diabetes mellitus, celiac disease, hypokalemia, degenerative disease of the nervous system, and long-term insulin use, was cognitively intact according to the most recent MDS assessment. Despite this, there was no documentation that a discharge notice was given to the resident or the Ombudsman prior to the resident's discharge in December 2025. Staff interviews confirmed that no discharge notice had been provided, as the resident was agreeable to leave, and that the Ombudsman had not been notified as of the interview date.
Failure to Staff RN 8 Hours Daily
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) on duty for at least eight hours a day, seven days a week, as required by regulations. Review of daily staffing records for the period from 08/06/2025 through 08/13/2025 showed that no RN was present at the facility on 08/08/2025, 08/09/2025, 08/10/2025, and 08/13/2025. This was confirmed during interviews with the Director of Nursing and the Administrator, who acknowledged that no RN was scheduled or worked on those days. The deficiency had the potential to affect all 74 residents in the facility, as indicated by the facility census.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 50 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillsboro Post Acute | 1.3 mi | ★★★★★ | 0 | 0 |
| Crestwood Ridge Skilled Nursing And Rehab | 1.5 mi | ★★★★★ | 1 | 0 |
| Edgewood Manor Of Greenfield | 15 mi | ★★★★★ | 5 | 0 |
| Greenfield Skilled Nursing And Rehabilitation | 15.6 mi | ★★★★★ | 6 | 0 |
| Monarch Meadows Nursing And Rehabilitation | 16.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillsboro Health And Rehab Llc.
100% money-back within 48 hours.
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.