Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Avamere Rehabilitation Of Hillsboro during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was left unsupervised off the facility premises in a busy street area after staff were told not to assist the resident back, and the resident was later found lost by police. The facility also failed to update care plans for two other residents with repeated elopement and fall events, including a resident who repeatedly tried to go to the bank and later fell from a wheelchair, and another resident with severe cognitive impairment who fell after being left alone during a fire drill.
A resident with severe cognitive impairment and Stage 2 pressure ulcers was not given ordered wound care consistently because the treatment order was entered incorrectly and later discontinued, leaving long gaps with no documented care. The wounds were inconsistently documented, worsened over time, merged into one large Stage 4 pressure ulcer with exposed bone and stool in the wound, and the resident was sent to the hospital.
Surveyors found widespread floor damage in multiple resident rooms and bathrooms, including cracks, gouges, separated seams, missing flooring, exposed subflooring, and a porous, discolored bathroom floor with a urine-like odor. Two residents also had light cords made from plastic trash bags because the cords were too short or unreachable; one resident had severe cognitive impairment and the other was cognitively intact. Staff and the Maintenance Director acknowledged the conditions were not homelike, and resident council members had already raised concerns about the poor condition of the floors.
A resident with diabetes and severe cognitive impairment was given a CBG check and insulin injection by an LPN in the dining room without permission, while other residents and a family member were present. The resident later said she/he preferred private care, and a phlebotomist also drew blood in the dining room with other residents present instead of offering a private area, despite the resident’s discomfort and the lab’s stated privacy policy.
Failure to honor a resident’s shower preferences: A cognitively intact resident with depression and significant bathing assistance needs repeatedly asked not to receive shower care from a specific CNA because the resident felt care was not thorough. Despite staff awareness of the preference, the CNA Assignment Restrictions Form was not updated, and the CNA continued to be assigned to the resident’s showers.
Failure to provide SNF ABN notifications to two residents with ended Medicare Part A coverage. Both residents remained in the facility after their Medicare benefits ended and were financially responsible for their care, but the record contained no documentation that the SNF ABN was given to the resident or representative to explain daily out-of-pocket costs. The SS Director stated the forms were not provided, and the Administrator acknowledged the omission.
A resident was transferred to the hospital after a change in condition, but the facility did not provide the required bed hold policy at the time of transfer. The policy required written notice upon admission and again at transfer or within 24 hours for an emergency transfer. Staff interviews confirmed the resident was not given the policy, and the LPN, RCM, and DNS acknowledged the omission.
Failure to Provide Meaningful Activities Based on Resident Preferences A resident with dementia, cognitive impairment, and limited English was not provided meaningful activities based on stated preferences for gardening, music, animals, and going outside. Records showed limited participation, while most activity logs documented keeping up with the news, which was not preferred. Observations found the resident in bed or wandering in a wheelchair with no activity materials available, and staff confirmed no one-on-one, group, or preference-based activities were provided.
A resident with diabetes and dementia had a raised growth on the left wrist that was noticed by a family member and later observed by staff, but the CNA did not notify the nurse and nurses did not document the finding during weekly skin audits. The TAR showed the skin audit task was completed, yet no skin assessment details were recorded, and the RCM and DNS confirmed the growth was missed, undocumented, and not reported to the provider.
Failure to provide upper extremity ROM services. A resident with hemiplegia/hemiparesis after a stroke had left-sided weakness, impaired mobility, and dependence for ADLs, but the record showed only lower-extremity passive ROM was provided. Staff observed the resident’s left arm flexed with the left thumb drawn into the palm, and interviews confirmed the resident had no upper-body ROM program despite being bed bound and at risk for contractures.
A resident with an indwelling catheter, severe cognitive impairment, UTI history, and CKD had the catheter drainage bag repeatedly observed lying on the floor despite the facility policy requiring it to be kept off the floor. Staff acknowledged the bag should not be on the floor and that the resident was known to move and drop it, but it remained there during multiple observations. In addition, a CNA was observed providing peri care and brief care, then emptying the catheter bag without changing gloves or performing hand hygiene before touching the drainage spout; the CNA later said he double-gloved and continued care without hand hygiene, and the IP stated this was inappropriate.
A facility failed to individualize and consistently implement psychosocial and safety care plans for two residents with mental health or trauma histories. One resident with depression, anxiety, and PTSD had a recent suicide attempt and was supposed to have the room door left open and hazards addressed, but staff repeatedly closed the door and left other cords and items accessible. Another resident was placed on suicide precautions after a reported pill-related comment, but staff treated the intervention as standard rather than person-centered, gave plastic utensils despite the resident’s objections, and left crochet supplies in place while staff gave conflicting accounts of the resident’s safety needs.
Survey Results Not Readily Accessible: The facility failed to ensure survey inspection results were readily accessible to residents and the public. Resident council members said they did not know where to find prior survey results or whether they could review them, and two locations in the facility contained Survey Results binders that did not include the most recent recertification survey results. The Administrator confirmed the binders only contained older survey results and that last year's survey results were not available for review.
Two residents did not receive care according to physician orders and facility protocols. One resident on an antidepressant with constipation risk went six days without a bowel movement; although Senna and MiraLAX were ordered per the bowel protocol, they were not administered, and only a suppository was given on the sixth day, contrary to the stepwise bowel regimen. Another resident with an amputation and multiple wounds had lubricant eye drops ordered twice daily and PRN for dry eyes, but the drops were not given for an extended period due to a transcription error, resulting in at least 28 missed doses. The same resident also had ordered wound care to the right leg and chest that was not performed on certain days when the resident was in conferences or meetings, with TAR entries indicating treatment was held and no documentation that the wound care was completed, despite the expectation that physician orders be followed.
A resident with a history of hip and femur fractures, identified as a high fall risk and requiring a two-person transfer with a Hoyer lift, was transferred by a CNA without assistance and without the lift. This resulted in the resident falling from the bed and sustaining a right distal femur fracture.
The facility failed to provide accessible overbed lights and television remotes for three residents, affecting their independence. A resident with chronic kidney disease was without a TV remote for over a month, while two other residents could not reach their overbed light cords. Staff acknowledged the need for accessibility, but the issues remained unresolved.
The facility failed to maintain accurate records for four residents, including discrepancies in care plans and incomplete vaccine consent forms. A resident with Huntington's disease had an inaccurate care plan regarding meal supervision, while three other residents had missing information on their vaccine consent forms, such as ID numbers and physician details. Staff interviews confirmed these deficiencies.
A resident with Huntington's disease requested a personal computer to meet psychosocial needs, but the facility failed to assist in purchasing it despite available funds. The resident, who was cognitively intact, expressed feeling cut off due to the lack of a computer. Staff and the administrator confirmed the oversight.
The facility failed to provide SNF ABN notifications to two residents who remained in the facility after their Medicare Part A benefits ended. This oversight was confirmed by the Social Services Director and acknowledged by the Administrator, placing residents at risk of unknown financial liabilities.
A resident with anemia and chronic kidney disease reported missing clothing and a personalized blanket, filing grievances with staff assistance. Despite the facility's policy to protect residents' items, the grievances remained unresolved, leading to the resident using donated clothing. The facility's administrator acknowledged the unresolved issue, highlighting a failure to follow up on grievances.
A facility failed to provide a person-centered activities program for a hospice resident with alcoholic cirrhosis. The resident, who valued activities like reading and music, was observed without access to these resources and did not participate in group activities. Staff interviews revealed a lack of awareness and training regarding the resident's needs, and the Activity Director admitted the care plan was not comprehensive. The resident's cognitive decline and increased dependency required more support, which was not provided.
A resident at moderate risk for falls exited a facility through an emergency exit door with a non-functioning alarm, resulting in a fall outside. The facility failed to investigate the environmental factors contributing to the incident, and the resident's care plan lacked clarity regarding bed height, leading to inconsistencies in its implementation.
The facility failed to maintain respiratory equipment for two residents, leading to potential respiratory concerns. A resident with chronic respiratory failure required continuous oxygen, and another with COPD used oxygen PRN. Both had oxygen concentrators with dusty filters, and staff confirmed the lack of a cleaning schedule.
A resident with Huntington's disease and major depressive disorder did not receive a trauma assessment as required by the facility's policy. Despite expressing feelings of depression and a willingness to discuss trauma history, the resident's needs were not addressed. Staff confirmed the oversight, and the facility administrator acknowledged the findings.
A resident with Huntington's disease and depression did not receive necessary behavioral health care. Despite moderate depression scores, no specific mood interventions were provided. The resident felt unsupported, and staff struggled to address emotional needs. The care plan was confusing, and interactions were limited to passive activities. The administrator acknowledged the need for improvement.
A resident admitted with gastroenteritis and colitis did not receive ordered physical and occupational therapy services due to oversight after multiple hospital stays. Despite physician orders, therapy evaluations were not conducted, and services were not resumed, leading to a decline in the resident's functional abilities.
The facility failed to notify the Ombudsman when two residents were transferred to the hospital. One resident, admitted with hypertrophic pyloric stenosis, was hospitalized for shortness of breath and fluid retention. Another resident, admitted with pneumonitis, was hospitalized multiple times for serious conditions, including a pulmonary embolism and sepsis. The facility lacked a process to notify the Ombudsman, as acknowledged by the administrator.
The facility failed to honor the rights of three residents to refuse room transfers. Despite residents' refusals to sign room move notifications, the facility proceeded with the moves, citing the need to condense rooms for new admissions and a misunderstanding of state regulations. The residents involved had various medical conditions, including anemia, respiratory failure, congestive heart failure, stroke, coronary artery disease, and urinary tract infections.
A resident with severe cognitive impairment and a history of walking around the facility eloped after being left unsupervised. The resident was found later at a hospital after being reported missing. Staff interviews revealed the resident had previously attempted to leave the facility but was usually redirected. On the day of the incident, the resident was not under direct supervision, and staff were unaware of the resident's whereabouts until it was too late.
Inadequate supervision and outdated care plans led to unsafe resident incidents
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with severe cognitive impairment who was allowed to be outside on the facility property independently, but was later found unsupervised in a busy arterial/commuter highway area. The resident had diagnoses including dementia, epilepsy, diabetes, a right above-the-knee amputation, limited English, hard-of-hearing status, and required one-person assistance with transfers. The resident’s care plan stated the resident could be outside on the facility property only independently, but the record contained no documented assessment showing the resident was safe to leave the premises or be in the community in a high-traffic area without supervision. On the day of the incident, a CNA saw the resident far from the facility on a busy street and approached after the resident reported difficulty getting back because of poor sidewalk conditions and said the resident had fallen. The CNA contacted the former administrator and was instructed not to assist the resident back to the facility and to leave the resident where he or she was. The CNA turned the wheelchair toward the facility, encouraged the resident to return, and left the resident on the busy street. Staff later searched for the resident but could not locate him or her, and the resident was eventually reported by police as lost and was returned to the facility by the resident’s daughter. The facility also failed to keep care plans accurate and updated for two residents with repeated elopement or fall-related events. One resident had a history of attempting to leave the facility to go to the bank, was found outside on one occasion and later left the facility again, fell from the wheelchair, and sustained a laceration requiring sutures; the record did not show the care plan was revised to address the repeated urge to leave. Another resident had severe cognitive impairment and multiple falls, including a fall during a fire drill after being left alone in a room with the door closed, despite care plan interventions stating the resident was not to be left unsupervised in the bathroom or alone in the room while up in the wheelchair.
Missed wound care led to worsening pressure ulcers
Penalty
Summary
The facility failed to provide necessary treatment to promote healing of pressure ulcers for one resident who was admitted with Stage 2 pressure ulcers to the left buttock and coccyx and had severe cognitive impairment and extensive ADL dependence. The resident’s admission wound orders called for daily cleansing and foam dressing changes, but the treatment order was entered incorrectly as PRN only and then discontinued, and no wound care was documented for 10 consecutive days after admission. When a new wound order was later entered for daily cleansing, wound cleanser, Vashe-moistened gauze, skin prep, and foam dressing, the record again showed missed treatment, including no documented wound care on one day after the order was discontinued and no wound care on two additional days after the next order was entered. Wound evaluations showed the two separate Stage 2 wounds initially had partial-thickness skin loss with light sanguineous drainage and no odor, but then worsened over time, with increasing size, development of granulation tissue and slough, and pain. Progress notes and provider notes showed inconsistent documentation of the resident’s skin status, with multiple notes stating the skin was intact and no wounds were present despite wound evaluations documenting active pressure ulcers. Staff later reported they relied on the TAR to determine whether wound care orders were active and whether treatment should be provided, and several staff could not recall performing the wound care or documented it. By 2/27/26, the wounds had merged into one large Stage 4 pressure ulcer with depth, exposed bone, foul odor, stool packed into the wound, and slough, and the resident was sent to the hospital.
Damaged flooring and improvised light cords in resident rooms
Penalty
Summary
The facility failed to ensure resident rooms and bathrooms were maintained in a safe, clean, comfortable, and homelike condition. Survey observations and record review identified damaged flooring in 21 of 55 sampled resident rooms, including cracks, gouges, scratches, separated seams, missing flooring, missing or lifting transition strips, and exposed subflooring. In one shared bathroom, the flooring around the toilet was discolored and porous, and the room had a strong urine-like odor with no visible urine present. The facility’s maintenance and homelike environment policies required the building to be kept in good repair and free from hazards and to maintain a clean, sanitary, and orderly environment. During a room observation, one resident room had multiple areas of floor damage, including a raised crack, missing flooring with exposed subfloor, a long scratch with visible subfloor, and multiple divots and gouges around the bed legs with dark staining and debris. A resident council discussion also reflected concern about the condition of the floors in resident rooms, with members stating the floors looked terrible and suggesting the damaged sections be cut out until replacement occurred. The Maintenance Director stated the room was one of the worst for floor damage and that repair had not yet been scheduled. Two residents were also observed with light cords made from plastic trash bags. One resident had severe cognitive impairment with a BIMS score of 4, and the other resident was cognitively intact with a BIMS score of 15. Both residents stated or were observed to have the improvised pull cords because the light cords were too short or not reachable. Staff stated that environmental issues were supposed to be entered into the facility’s TELS system or otherwise reported to maintenance, and the Maintenance Director acknowledged the trash bag pull cords were not homelike and stated he had replacement pull cords in stock.
Failure to Protect Resident Privacy During CBG, Insulin, and Blood Draws
Penalty
Summary
The facility failed to ensure resident care was provided in a manner that maintained and promoted dignity for one resident with diabetes and dementia. The resident’s quarterly MDS dated 4/20/26 indicated a BIMS score of 3, showing severe cognitive impairment. On 5/4/26 at 12:15 PM, an LPN performed a CBG check on the resident in the dining room, and at 12:19 PM raised the resident’s shirt and administered insulin into the abdomen in the dining room. These actions were done without asking the resident’s permission to complete the CBG check and insulin administration in front of others, and there were eleven residents and one family member present. The LPN later confirmed he did not ask the resident for permission to do the CBG check and insulin injection in the dining room. The resident stated she/he preferred to have insulin administered in a private space, and a family member stated the resident had been very modest all her/his life and would want CBG testing and insulin injections completed in private. On 5/6/26, a phlebotomist was observed drawing blood from the resident’s left arm in the dining room while three other residents were present, without offering to take the resident to a private area. The phlebotomist stated she typically drew blood from residents in the dining room and had asked the resident for permission, but had not asked the other residents if they were okay with being present. The resident later stated she/he was not comfortable having blood drawn in the dining room, and the lab supervisor and phlebotomist supervisor stated their policy was to draw blood in resident rooms, not in the dining room with others present, due to sanitary concerns and to protect privacy.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to promote resident self-determination for one resident who was cognitively intact and required substantial-to-maximal assistance with bathing. The resident was admitted with diagnoses including depression, and the facility’s Dignity Policy stated that resident goals, choices, preferences, values, and beliefs were to be respected and honored to the extent possible. The resident’s care plan identified a need for physical assistance from one staff member with bathing, and the shower task log showed that Staff 32 assisted the resident with a shower. During observations and interviews, the resident stated that several requests had been made not to have Staff 32 assist with showers because Staff 32 did not wash the resident’s left side thoroughly, but Staff 32 continued to provide shower assistance. The resident also stated that scheduled shower days were stressful because the resident did not know who would provide care or whether preferences would be honored. Staff interviews confirmed awareness of the resident’s preference not to receive shower assistance from Staff 32, that the preference form had not been updated to reflect current preferences, and that the resident continued to receive showers from Staff 32 despite the expressed preference not to.
Failure to Provide SNF ABN Notifications
Penalty
Summary
The facility failed to provide SNF ABN notifications to 2 of 3 sampled residents reviewed for beneficiary notification. Resident 67 was admitted with Medicare Part A benefits, and a NOMNC dated 4/15/26 indicated the resident’s Medicare Part A benefits ended on 4/17/26. The record showed the resident remained in the facility and was financially responsible for care from 4/18/26 through 4/20/26, but there was no documentation that the SNF ABN notification was provided to the resident or the representative to inform them of the daily out-of-pocket expenses. Resident 100 was admitted with Medicare Part A benefits, and a NOMNC dated 3/13/26 indicated the resident’s Medicare Part A benefits ended on 3/15/26. The record showed the resident remained in the facility and was financially responsible for care from 3/16/26 through 3/17/26, but there was no documentation that the SNF ABN notification was provided to the resident or the representative to inform them of the daily out-of-pocket expenses. Staff 13, the Social Services Director, stated the SNF ABN form was not provided to either resident or their representative, and Staff 1, the Administrator, acknowledged both residents were not provided the SNF ABN form.
Failure to Provide Bed Hold Policy at Hospital Transfer
Penalty
Summary
The facility failed to provide Resident 89 with a bed hold policy when the resident was transferred to the hospital after a change in condition. The facility’s Bed Hold and Return Policy dated 10/2022 stated that residents or their representatives were to receive written information about the facility and state bed hold policies upon admission and again at the time of transfer or within 24 hours if the transfer was an emergency. A 2/11/26 progress note documented that Resident 89 was assessed by an LPN and determined to require transfer to the hospital. Record review and staff interviews confirmed that Resident 89 was not given a physical copy of the bed hold policy on or after the transfer. The LPN who completed the assessment stated she did not include bed hold policy information when a resident was transferred to the hospital, and the Resident Care Manager stated residents were provided bed hold policy information upon admission but not when discharged to the hospital and expected to return. The DNS confirmed Resident 89 was not provided the bed hold policy when transferred to the hospital.
Failure to Provide Meaningful Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide meaningful activities for a resident with cognitive impairment, a right leg above-the-knee amputation, diabetes, dementia, and epilepsy. The resident’s activity profile showed Spanish as the primary language with minimal English and identified interests including gardening, watching TV, religious studies, listening to music, being around animals, and going outside when the weather was good. The resident’s care plan also identified a need for independent or self-directed activities and noted that activity staff were to provide supplies such as reading materials, puzzles, word searches, cards, and crafts. The resident’s later records showed severe cognitive deficits and a psychosocial care plan added that one-on-one visits with a Spanish interpreter were needed, the resident should be encouraged to go outside in the courtyard when applicable, and hallway activities such as music, audio books, games, snacks, and drinks should be offered. Another care plan later stated the resident was no longer safe to go outside unsupervised and that social services and the Resident Care Manager were to determine why the resident wanted to leave and develop an activity plan and interventions. However, the social service director stated she was not notified of that intervention and did not develop any activity plans or interventions, and the Resident Care Manager stated she did not determine the reasons for the resident wanting to leave or develop an activity plan. Activity logs showed only limited participation, including watching TV on two days and going outside once, while most entries documented the resident keeping up with the news, which was not a preferred activity. Multiple observations showed the resident either in bed with no TV or music playing or wandering the halls in a wheelchair, with no independent activity materials available in the room. The resident was not seen outside, not seen in hallway or group activities, and no one-to-one activities were provided. Staff interviews confirmed the resident primarily wandered the facility, spoke Spanish, was no longer allowed to go outside alone, and had not been provided activities related to the resident’s preferences such as gardening or being outside.
Failure to Document and Monitor a Resident’s Skin Growth
Penalty
Summary
The facility failed to follow physician orders and monitor skin conditions for a resident with diabetes and dementia. The resident’s 4/20/26 quarterly MDS indicated no skin issues and severe cognitive impairment. The facility had a physician order dated 7/14/25 directing weekly skin audits, with nurses to mark yes or no for any new skin conditions and document findings in the resident’s clinical record. However, the TAR showed weekly skin audit checks on 4/13/26, 4/20/26, 4/27/26, and 5/4/26 without any documentation of what was observed, and there was no documentation about the resident’s left wrist growth. A family member stated she noticed a growth on the top of the resident’s left wrist two to three weeks before 5/4/26 and asked a CNA to notify the nurse because she wanted it examined for possible removal, but no follow-up occurred. On 5/6/26, the resident was observed to have a raised, rough, dry growth about the size of a pencil eraser on the top of the left wrist, and the resident stated it sometimes bothered them and they kept a watch pulled back away from it. A CNA stated she knew about the growth but did not notify the nurse, and multiple nurses stated they were unaware of it. The RCM and DNS confirmed the growth was not documented, not identified during the skin audit, and the provider was not notified.
Failure to Provide Upper Extremity ROM Services
Penalty
Summary
The facility failed to ensure a resident with limited ROM received necessary services to prevent further decrease in ROM. Resident 64 was admitted with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left side. The resident’s records showed left-sided weakness, impaired mobility, dependence on staff for all ADLs except eating and oral hygiene, and a care plan that included turning and repositioning in bed every two hours, mechanical lift transfers, and therapy evaluation if decline occurred. A review of the restorative nursing records showed the resident received passive ROM to the left and right lower extremities three times weekly from 4/7/26 to 5/6/26. No evidence was found in the clinical record that the resident received assistance with upper body ROM or ongoing assessments and monitoring related to upper body functioning. During observation, the resident was in bed with the left arm bent at the elbow and the left thumb bent into the palm of the hand. The resident stated the left side was paralyzed, that the fingers on the left hand had to be moved with the right hand, and that the resident wanted upper body ROM because the left arm was often sore. Staff interviews confirmed the resident did not have an upper extremity ROM program. CNAs stated restorative aide staff provided ROM and that the resident’s left hand was contracted. The restorative aide stated he provided lower body restorative exercises three times weekly but did not know why the resident did not have an upper body ROM program. The Director of Rehabilitation, LPN Resident Care Manager, and DNS all stated the resident was appropriate for upper extremity restorative exercises and that residents who were bed bound or had limited mobility were at risk for contracture development. The LPN also stated she did not complete specific assessments or ongoing monitoring related to contracture prevention or development and relied on CNAs to tell her when residents needed something.
Inadequate Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to provide adequate catheter care for one resident with an indwelling catheter, who was admitted with diagnoses including UTI, inflammatory reaction due to indwelling urethral catheter, and chronic kidney disease. The resident’s admission MDS showed a BIMS score of 4, indicating severe cognitive impairment. The facility’s catheter care policy stated that catheter tubing and the drainage bag must be kept off the floor, but repeated observations on multiple days showed the resident’s catheter drainage bag lying flat on the floor in the resident’s room, including beside the bed and beside the wheelchair while the resident was seated at the sink. Staff acknowledged that the catheter drainage bag should not be on the floor and that it was not sanitary, with potential for infection. One RN stated the resident was known to take out and move the catheter and drop it on the ground, and that management was aware of the behavior. During catheter care, a CNA was observed providing peri care and changing the brief, then emptying the catheter drainage bag without changing gloves or performing hand hygiene before touching the drainage spout. The CNA later stated he had double-gloved, removed one pair, and did not perform hand hygiene before handling the catheter bag. The infection preventionist stated staff should not double glove and continue care without doffing gloves, performing hand hygiene, and donning new gloves when moving from a contaminated site to a clean site.
Failure to Individualize Psychosocial and Safety Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans that addressed the emotional and psychosocial needs of two residents who had mental health histories and recent statements or behaviors related to self-harm. One resident was admitted with depression, anxiety, and PTSD, had a quarterly MDS showing cognitive intactness and depressed mood, and after being sent to the ED for altered mental status with an open bottle of OTC pain medicine and scattered tablets, returned to the facility on frequent checks with safety interventions. The care plan included keeping the room door propped open, removing hazardous objects, and shortening cords, but staff observations showed the door was repeatedly closed, the resident was left alone with access to other cords and items in the room, and multiple staff members were unaware of or inconsistent about the safety measures. The resident stated the door was supposed to remain open for safety, that staff kept closing it, and that the resident had not been talked to about other cords in the room. Staff interviews showed conflicting understanding of the intervention: some staff believed the door could be closed because the resident was not a fall risk, while others knew it was supposed to remain cracked open after the suicide attempt. The social services director and nursing staff acknowledged that the resident had access to other long cords, a plastic bag, and an exercise band, and that these items had not been addressed in the resident’s safety planning. The second resident had dementia and a trauma care plan calling for participation in decision-making. After a reported statement about taking a bunch of pills, the resident was placed on alert and frequent checks and the care plan was updated with suicide-risk interventions, including plastic utensils and removal of hazardous objects. However, staff later described the statement as a joke, and the resident said the interventions were not discussed with them and were not person-centered. The resident was observed receiving plastic silverware while still having access to crochet supplies and a crochet hook, and staff gave inconsistent accounts about whether the resident should have regular silverware or plastic utensils, whether the resident was informed, and whether other potentially hazardous items were considered.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure state survey inspection results were readily accessible for resident council members and the public. During interview on 5/7/26, five of five resident council members stated they did not know where to access a copy of the previous year's survey results or whether they were allowed to review past survey results. A tour of the facility on 5/7/26 found one clear plastic file folder holder near the kitchen entrance labeled Survey Results with a three-ring binder containing survey results, but the most recent results in that binder were dated 8/25/23 for the 7/31/23 recertification survey and 4/19/24 complaint survey, with no survey results for the 1/2025 recertification survey. On 5/8/26, Staff 43 identified a second Survey Results binder at the receptionist's desk, and review of that binder also showed the last survey results were dated 8/25/23 with no survey results for the 1/2025 recertification survey. The Administrator confirmed the binders contained survey results for the 7/31/23 recertification survey and that last year's survey results were not available for review.
Failure to Follow Bowel Protocol and Physician Orders for Eye and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its bowel care protocol and physician orders for bowel management and eye lubrication, resulting in missed treatments for two residents. For one resident with hypothyroidism, breast cancer, and depression, the care plan identified constipation as a side effect of an antidepressant. The facility’s 2025 bowel care protocol required a stepwise approach to constipation, including administration of Senna after 3 days without a bowel movement, MiraLAX after 4 days, a suppository after 5 days, and an enema after 6 days. The resident’s MAR showed that although Senna and MiraLAX were prescribed, neither was administered during a 6‑day period without a bowel movement from 11/7/25 to 11/13/25, and only a suppository was given on the sixth day. Nursing staff confirmed that suppositories were intended to be used after other bowel interventions failed and that this sequence did not follow the facility’s bowel care protocol, and a CMA reported being unaware of the protocol. The deficiency also includes failures to follow physician orders for eye drops and wound care for another resident with an infected amputation stump, an open wound on the right thigh, acute posthemorrhagic anemia, and an above‑knee amputation. A physician order required lubricant eye drops twice daily and as needed for dry eyes, but the MAR showed the drops were not administered for a 16‑day period, and an LPN/Resident Care Manager stated the order had been transcribed incorrectly and that the resident missed at least 28 doses, placing the resident at risk for discomfort related to dry eyes. Additional physician orders required wound care to the resident’s right leg twice daily, then once each day shift, and daily chest wound care. On specific dates, the TAR reflected a code to hold treatment or see a nurse note, and progress notes documented a care conference or a meeting with social services, with no documentation that the ordered wound care was completed on those days. The LPN involved stated she did not complete the wound care when the resident was in these meetings, and the DNS stated that physician orders were to be followed.
Failure to Follow Transfer Protocol Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to implement care plan interventions designed to prevent falls for a resident with a history of right hip and femur fractures. The resident was identified as a high fall risk and required a two-person transfer using a Hoyer lift, as documented in the care plan. Despite these interventions, a certified nursing assistant (CNA) attempted to transfer the resident from a wheelchair to bed without the required assistance and without using the Hoyer lift. During this transfer, the resident slid from the edge of the bed, twisted their ankle, and fell onto their right knee. As a result of the fall, the resident sustained a right distal femur fracture and required hospital evaluation. Facility records and staff interviews confirmed that the CNA did not follow the resident's care plan, which directly led to the accident and injury. The facility's investigation determined that the failure to adhere to the prescribed transfer protocol resulted in the resident's fall and subsequent fracture.
Inaccessible Overbed Lights and TV Remotes
Penalty
Summary
The facility failed to ensure that overbed lights and television remotes were accessible for three residents, which compromised their independence. Resident 6, admitted with chronic kidney disease, was cognitively intact but dependent on staff for transfers. The resident had been without a television remote for over a month, requiring assistance to change channels or turn the television on or off. Despite reporting the missing remote to staff, no action was taken, leading to frustration and a loss of independence for the resident. Staff members were unaware of the issue, and the Maintenance Director was not informed about the missing remote. Residents 362 and 364 also faced accessibility issues with their overbed lights. Resident 362, admitted with pneumonitis, could not reach the overbed light cord, which was only 3 inches long. Similarly, Resident 364, admitted with severe protein-calorie malnutrition, had an overbed light cord that was 11 inches long and out of reach. Staff acknowledged that residents should be able to operate their lights independently, and the Maintenance Director confirmed that cords should be at least 24 inches long to ensure accessibility. The Administrator confirmed that the cords should be long enough to drape on the bed for resident access.
Inaccurate Resident Records and Incomplete Vaccine Consent Forms
Penalty
Summary
The facility failed to ensure the accuracy of resident records for four out of five sampled residents, specifically regarding vaccination records. Resident 31, who was admitted with Huntington's disease, had discrepancies in their care plan related to meal supervision. Observations and staff interviews revealed inconsistencies between the care plan and the actual supervision provided during meal times. Staff members provided conflicting information about the level of supervision required, and it was acknowledged by the facility's administration that the care plan was inaccurate. Additionally, the facility did not maintain complete and accurate vaccine consent forms for Residents 6, 35, and 363. The consent forms were missing critical information such as ID numbers, nursing care center details, addresses, physician information, and dates of signatures. Staff interviews confirmed that the expectation was for these forms to be fully completed and dated before vaccine administration. The Director of Nursing Services confirmed the deficiency in the completion of these forms, which is a requirement for proper documentation and resident care.
Failure to Honor Resident's Request for Personal Computer
Penalty
Summary
The facility failed to honor a resident's request for a personal computer, which was necessary to meet the resident's psychosocial and activity needs. Resident 31, who was admitted in December 2019 with Huntington's disease, requested a personal computer during a care conference on December 3, 2024. The resident was cognitively intact and had the financial means to purchase the computer, as confirmed by a social service note and the resident's representative payee, who loaded funds onto the resident's Visa card on December 4, 2024. Despite the availability of funds and the resident's clear request, the facility did not assist in purchasing the computer. On January 21, 2025, the resident confirmed that they had not received the computer and expressed feelings of being cut off. Staff members acknowledged the request and the availability of funds but confirmed that the computer had not been purchased. The facility administrator also acknowledged the failure to assist the resident in acquiring the computer.
Failure to Provide SNF ABN Notifications
Penalty
Summary
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) notifications to two residents who were reviewed for Beneficiary Notification. Resident 12 was admitted with Medicare Part A benefits, and the facility's records indicated that the last covered day for Medicare Part A services was 11/1/24. However, the resident remained in the facility without receiving the required SNF ABN notification to inform them or their representative of potential out-of-pocket expenses. Staff 12, the Social Services Director, confirmed that the facility did not issue SNF ABN notifications to residents when they were discharged from Medicare Part A services and remained in the facility. Similarly, Resident 48 was admitted with Medicare Part A benefits, and the facility's records showed that the last covered day for Medicare Part A services was 10/28/24. Like Resident 12, Resident 48 remained in the facility without receiving the necessary SNF ABN notification. Staff 12 confirmed this oversight, and Staff 1, the Administrator, acknowledged that the facility did not issue SNF ABN notifications to residents and their representatives as required. This failure placed residents and their representatives at risk for lack of knowledge regarding their right to appeal and unknown financial liabilities.
Failure to Resolve Resident Grievance on Missing Personal Property
Penalty
Summary
The facility failed to address a grievance related to personal property for a resident, identified as Resident 38, who was admitted with anemia and chronic kidney disease. The resident, who was cognitively intact, reported missing several clothing items and a personalized blanket received as a birthday gift. Despite filing grievances with the assistance of staff, the items remained unresolved, leading to the resident running out of clothing and having to use items from the donated rack in the laundry. Staff interviews revealed that the resident had submitted Lost or Damaged Items forms several months prior, specifically on 9/19/24, for the missing items. However, the items were neither located nor replaced. The facility's administrator acknowledged the unresolved grievance and stated that it was expected that grievances should be followed up with the resident and family for an agreeable resolution. This lack of resolution placed residents at risk for unresolved grievances, as the facility did not adhere to its policy of protecting residents' items from theft or loss.
Failure to Provide Person-Centered Activities for Hospice Resident
Penalty
Summary
The facility failed to provide an ongoing person-centered activities program for a resident who was admitted with alcoholic cirrhosis of the liver and was on hospice care. The resident's Admission MDS indicated that activities such as reading, listening to music, and participating in religious services were important. However, observations and interviews revealed that the resident did not receive one-to-one visits, did not have access to their computer, music, or newspapers, and did not participate in group activities. The resident expressed a desire to engage in activities but was unable to do so due to a lack of support and resources. Staff interviews indicated a lack of awareness and training regarding the resident's activity interests and needs, particularly for those on hospice care. The Activity Director acknowledged that the resident's care plan was not comprehensive and that the resident was not included in activities such as Bible study, which they had expressed interest in. The staff also noted the resident's cognitive decline and increased dependency, which required more support to engage in activities. The facility's failure to update the resident's care plan and provide appropriate activities contributed to the deficiency.
Failure to Ensure Safe Environment and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment and implement care plan interventions to prevent falls for a resident, leading to a deficiency. The resident, who was admitted with alcoholic cirrhosis and ascites, was identified as being at moderate risk for falls. Despite this, the resident was able to exit the facility through an emergency exit door that did not have a functioning alarm, resulting in a fall outside the facility. The staff member assigned to the resident noticed the door was not completely closed and found the resident outside, having sustained minor injuries. The investigation revealed that the emergency exit door alarm was not functioning, and there was no evidence of a thorough investigation into the environmental factors contributing to the resident's elopement and fall. The facility's Code Pink Policy referenced a Door Alarm Policy that did not exist, and the Maintenance Director was unaware that the door required a working alarm. The Administrator confirmed that the door was not investigated following the incident, which should have been done. Additionally, the resident's care plan directed that the bed be at an appropriate height, but observations showed inconsistencies in the bed's height when the resident was in bed. Staff members were unclear about the care plan's instructions, with some believing the bed should be in the lowest position when occupied due to the resident's fall history. The Administrator and other staff acknowledged the care plan's lack of clarity regarding the bed's position.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment for two residents, leading to potential respiratory concerns. Resident 9, admitted with chronic respiratory failure and a fracture, required continuous oxygen. On observation, the oxygen concentrator's external foam filter was found with a thick layer of dust, and the resident expressed concern about its cleanliness. Staff acknowledged the dirty filter, and it was revealed that the facility lacked a cleaning schedule for the oxygen concentrators. Similarly, Resident 10, admitted with chronic obstructive pulmonary disease and cellulitis, required PRN oxygen use. The oxygen concentrator for this resident also had a dusty foam filter, and the resident used the concentrator as needed. Staff confirmed the filter's condition and the absence of a cleaning schedule for the equipment.
Failure to Conduct Trauma Assessment for Resident
Penalty
Summary
The facility failed to identify and address a resident's past history of trauma and potential triggers for re-traumatization, as required by their Trauma-Informed Care and Culturally Competent Care Policy. This policy mandates universal screening of residents for possible exposure to traumatic events, including trauma history and related symptoms, to inform individualized care plans. However, it was found that Resident 31, who was admitted in December 2019 with Huntington's disease and major depressive disorder, had not received such a trauma assessment. The resident expressed feelings of depression and noted that no one at the facility had discussed their trauma history or potential triggers with them. Observations and interviews with staff confirmed the deficiency. On two separate occasions, Resident 31 was observed expressing feelings of depression and a willingness to discuss their trauma history. Staff 29, an RN, noted that the resident's mood varied and they had outbursts. Staff 12 from Social Services confirmed that all residents were supposed to receive a trauma assessment and acknowledged that Resident 31 had not received one. The facility administrator, Staff 1, acknowledged the findings but did not provide additional information.
Failure to Provide Behavioral Health Care for Resident with Depression
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with Huntington's disease, major depressive disorder, and anxiety. The resident's PHQ-9 scores indicated moderate depression over several months, yet there was no evidence of specific mood interventions being offered. The resident expressed feeling generally depressed and not being offered the opportunity to talk to someone about their depression. Staff interviews revealed inconsistencies in addressing the resident's emotional needs, with social services staff unable to identify specific interventions following increased depression scores. The resident's care plan for psychosocial well-being was found to be confusing, and staff had difficulty understanding the resident due to slurred speech. The activity director's interactions with the resident were limited to dropping off puzzles and newspapers, with no active engagement in addressing psychosocial well-being. The facility administrator acknowledged the findings and recognized the need for improvement in the resident's care plans.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide physical and occupational therapy services as ordered for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including gastroenteritis and colitis, had physician orders for physical therapy (PT) and occupational therapy (OT) as indicated. However, the resident's quarterly MDS indicated that no PT or OT services were provided during the review period. Staff interviews revealed that the resident was motivated and had been doing well with ambulation before multiple hospital stays, but therapy services were not resumed upon readmission to the facility. The Rehab Director acknowledged that despite the physician orders, evaluations and therapies were not initiated due to the resident's frequent hospitalizations. The physician expressed an expectation that therapy orders would be communicated and evaluations completed as ordered. The Director of Nursing Services and Regional Nurse Consultant admitted that the resident was overlooked, and the necessary evaluations were not conducted. The facility administrator also stated that it was expected for residents to be evaluated for PT and OT per physician orders upon admission or readmission, which did not occur in this case.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman when residents were transferred to the hospital, as required. This deficiency was identified for two residents who were hospitalized multiple times. Resident 60, admitted in November 2024 with hypertrophic pyloric stenosis, was sent to the hospital on November 13, 2024, for shortness of breath and fluid retention. A review of Resident 60's clinical record showed no evidence that the Ombudsman was notified of the transfer. Similarly, Resident 40, admitted in October 2024 with pneumonitis, was hospitalized on several occasions for various serious conditions, including a pulmonary embolism and sepsis. Despite these multiple hospitalizations, there was no indication in Resident 40's medical records that the Ombudsman was informed of any of these transfers. The facility's administrator acknowledged the requirement to notify the Ombudsman but admitted that the facility lacked a process to implement this requirement.
Failure to Honor Residents' Right to Refuse Room Transfers
Penalty
Summary
The facility failed to honor the rights of residents to refuse room transfers, affecting three residents who were part of a sample review for residents' rights. Resident 5, admitted with anemia and respiratory failure, was moved to a different room despite refusing to sign the room move notification. The move was justified by the facility as necessary due to the transition from skilled services to ICF services. Staff acknowledged that Resident 5 refused to sign the notification, but the move proceeded after a seven-day notice was provided. Similarly, Resident 7, with diagnoses of congestive heart failure and stroke, and Resident 19, with coronary artery disease and a urinary tract infection, were also moved to different rooms against their wishes. Both residents refused to sign the room move notifications, citing their desire to remain in their current rooms. Staff confirmed that room moves were discussed in meetings, and despite residents' refusals, the moves were executed based on the facility's interpretation of state regulations, which they believed required only notification of the move, not resident consent.
Failure to Evaluate Elopement Risks Leads to Resident Elopement
Penalty
Summary
The facility failed to evaluate elopement risks for a resident with severe cognitive impairment, leading to an unsafe elopement incident. The resident, diagnosed with dementia, was admitted in August 2022 and had a history of walking around the facility. On July 26, 2024, the resident was reported missing after being last seen in the dining room. Staff members were engaged in other tasks, and the resident was not immediately noticed missing. The resident was later found by a passerby and taken to a nearby hospital's emergency department after falling, but fortunately, sustained no serious injuries. Interviews with staff revealed that the resident was known to enjoy walking and had previously attempted to leave the facility, although they were usually redirected by staff. On the day of the incident, the resident was not under direct supervision, and staff were unaware of the resident's whereabouts until it was too late. The resident had been on 15-minute checks, but this was the first time the assigned CNA was responsible for the resident. The lack of a comprehensive elopement risk evaluation and adequate supervision contributed to the resident's ability to leave the facility unnoticed.
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 524 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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 Health & Rehabilitation Center | 1.3 mi | ★★★★★ | 3 | 0 |
| Forest Grove Post Acute | 4.8 mi | ★★★★★ | 0 | 0 |
| Marquis Forest Grove Post Acute Rehab | 5.3 mi | ★★★★★ | 5 | 0 |
| Maryville | 7.6 mi | ★★★★★ | 1 | 0 |
| Beaverton Post Acute Care Of Cascadia | 9.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.