Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillsboro Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff observed two cognitively impaired residents engaging in intimate behaviors, including inappropriate touching and offering money, and determined through evaluation that neither could consent to such activity. Despite these findings, the incident was not reported to the State Agency as required, and the administrator confirmed the lack of reporting.
Two residents with cognitive impairments, both lacking capacity to consent to sexual activity, were observed by staff engaging in intimate behaviors, including kissing and inappropriate touching. Staff separated the residents, but no investigation into the incidents was conducted, and the administrator could not provide evidence of any follow-up.
A resident with hemiplegia and hemiparesis, who used an electric wheelchair and was care-planned for a seat belt, was found on the floor with a leg laceration after sliding out of the wheelchair. Staff were aware the seat belt was too small and could not be used, but did not report or address the issue, and there was uncertainty among staff about the care plan requirements at the time of the incident.
A resident with severe cognitive impairment and documented preferences for reading and other leisure activities did not have a care plan or Kardex that included individualized activity interventions. Staff were unaware of the resident's specific interests, and observations showed the resident without access to preferred activities or materials, resulting in unmet psychosocial needs.
A resident with impaired hand control and a need for supervision with personal hygiene was not provided assistance with shaving as outlined in the care plan. Staff confirmed that the resident was unable to shave independently and was not offered help as required, resulting in inadequate grooming and hygiene care.
A resident with severe liver disease was prescribed two tablets of oxycodone for pain levels of eight to ten, but staff repeatedly administered this dose for lower pain scores, sometimes without accurately assessing pain. Multiple staff confirmed they did not follow the physician's order, and the DON acknowledged the orders were not implemented as required.
A resident with COPD and other chronic conditions experienced significantly low oxygen saturations, which were repeatedly reported by a CNA to an LPN and a Resident Care Manager. Despite standing orders and care plan directives, staff delayed both the administration of oxygen and the resident's transfer to the hospital. The resident was later diagnosed with hypoxic respiratory failure, and facility leadership confirmed that timely respiratory interventions were not provided.
A resident with severe cognitive impairment and high risk for pressure ulcers did not receive required weekly skin observations or timely wound care. Staff failed to document new skin impairments, did not act on a hospice aide's note about a new wound, and did not implement a wound dressing order. The pressure ulcer was discovered by hospice staff before facility staff, and the facility's investigation confirmed lapses in skin/wound management and communication.
The facility did not accurately post RN staffing information on several days, as confirmed by the staffing coordinator, resulting in incorrect nurse staffing data being displayed.
Failure to Report Alleged Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency involving two residents with cognitive impairments. One resident, admitted with dementia and a BIMS score indicating severe cognitive impairment, and another resident with a moderate cognitive impairment, were both determined through Sexual Capacity Evaluations to lack the cognitive ability to consent to sexual activity. On two occasions, staff observed these residents engaging in intimate behaviors, including kissing and inappropriate touching, with one resident offering money to the other. Staff intervened and separated the residents each time. Despite these observations and the completion of sexual consent evaluations confirming both residents' inability to consent, there was no evidence that the incident was reported to the State Agency as required. The administrator acknowledged the lack of reporting and confirmed it was his responsibility to do so. The failure to report the suspected abuse placed the residents at risk.
Failure to Investigate Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to investigate allegations of abuse involving two residents with cognitive impairments. One resident with severe dementia and another with moderate cognitive impairment were both determined, through Sexual Capacity Evaluations, to lack the capacity to consent to sexual activity. On two occasions, staff observed these residents engaging in intimate behaviors, including kissing and inappropriate touching, with one resident offering money to the other. Staff intervened and separated the residents, but there was no evidence that an investigation into the incidents was conducted. The administrator confirmed that it was his responsibility to complete such investigations but was unable to locate any documentation that an investigation had occurred.
Failure to Provide Adequate Supervision and Assistance Devices to Prevent Resident Accident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis following a stroke, who used an electric wheelchair and was care-planned for a seat belt-gait belt, was not provided with adequate supervision and assistance devices to prevent accidents. The care plan specified the use of a seat belt, but staff were unable to secure it around the resident because it was too small, and this issue was known but not reported or addressed. The resident subsequently slid out of the wheelchair, sustained a leg laceration, and had to call emergency services for assistance after yelling for help without response. Staff interviews revealed uncertainty about the care plan requirements and whether the seat belt was in use at the time of the fall, indicating a lack of adherence to the care plan and communication regarding the resident's safety needs.
Failure to Develop Resident-Centered Activity Care Plan
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident with severe cognitive impairment and a diagnosis of dementia. The resident's Minimum Data Set (MDS) and activity assessments indicated preferences for reading, music, animals, fresh air, and specific types of books, such as murder mystery and suspense. Despite these documented preferences, the care plan and Kardex lacked specific interventions or directions for staff to provide or facilitate these activities. Observations over several days showed the resident in bed without access to reading materials, music, or other preferred activities, and staff interviews revealed they were unaware of the resident's specific interests beyond a general preference to stay in bed. Activity participation records showed the resident did not attend group activities like Bingo and primarily engaged with reading materials when available, but there was no consistent provision of preferred books or other leisure activities. Staff responsible for activities and direct care confirmed that the care plan and Kardex did not include individualized activity preferences or instructions, and the resident was not regularly offered opportunities for meaningful engagement as indicated by their documented interests and needs.
Failure to Provide Required Assistance with Grooming and Hygiene
Penalty
Summary
A deficiency was identified when a resident with nephrogenic diabetes insipidus and ataxia, who was cognitively intact but required supervision or touching assistance for personal hygiene, was not provided necessary care for grooming. The resident's care plan specified the need for maximal or substantial assistance with showers on specific days and supervision or touch assistance for grooming and personal hygiene. During an observation, the resident was noted to have a thick cluster of dark hairs on the chin and reported being unable to shave independently due to impaired hand control. The resident stated that assistance with shaving was supposed to be provided on shower days but was not offered that week. Interviews with CNAs and an LPN confirmed that the resident was unable to shave independently and was expected to receive assistance with shaving, particularly on shower days. Staff acknowledged that the resident was not offered shaving assistance as required, and the Director of Nursing Services confirmed that residents needing ADL assistance should receive it automatically, without having to request it. The failure to provide this assistance resulted in the resident not receiving appropriate grooming and hygiene care.
Failure to Follow Opioid Dosing Parameters for a Resident
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not adhering to physician orders regarding the administration of opioid pain medication. The resident, who had severe liver disease with ascites, was prescribed two tablets of oxycodone every four hours as needed for pain levels of eight to ten out of ten. However, medication administration records showed that staff repeatedly administered two tablets of oxycodone for pain levels below the prescribed threshold, including pain levels as low as three. Multiple staff members confirmed that they either did not assess the resident’s pain level accurately or administered the higher dose regardless of the actual pain score. Interviews with staff revealed that some did not consistently ask the resident for their pain level, instead recording or assuming higher pain scores to justify administering two tablets. One staff member admitted to mistakenly giving two tablets when only one should have been given, and another stated that the resident was clear in communicating pain but still received the higher dose on several occasions. The Director of Nursing confirmed that physician orders were not followed as required, resulting in the resident receiving more opioid medication than indicated by the order parameters.
Failure to Provide Timely Respiratory Intervention for Resident with Low Oxygen Saturation
Penalty
Summary
A resident with a history of COPD, chronic kidney disease, and atrial fibrillation was admitted to the facility and had standing orders for supplemental oxygen to maintain saturations above 89%, with instructions to increase oxygen up to 2 liters before notifying a provider. The resident's care plan directed staff to monitor for breathing difficulties and signs of acute respiratory insufficiency. On the morning in question, the resident was found to have oxygen saturations as low as 64%, which were confirmed by repeated checks. The CNA reported these findings multiple times to both an LPN and the Resident Care Manager/LPN, but the Resident Care Manager delayed addressing the concern, and no oxygen was administered to the resident at that time. The resident was not transferred to the hospital until several hours later, where they were diagnosed with hypoxic respiratory failure. Staff interviews confirmed that the low oxygen saturations were reported and recognized, but appropriate interventions, including the administration of oxygen, were not initiated in a timely manner. Facility leadership acknowledged that the standard of practice would have been to reassess the resident, provide oxygen, and complete a full set of vitals before determining whether to send the resident to the hospital or contact the physician. The lack of timely evaluation and intervention was identified as a deficiency in providing appropriate and timely respiratory care.
Failure to Conduct Weekly Skin Observations and Timely Pressure Ulcer Treatment
Penalty
Summary
Facility staff failed to conduct weekly skin observations and timely evaluations for a resident with severe cognitive impairment, Alzheimer's disease, and diabetes mellitus, who was at high risk for pressure ulcers and dependent on staff for bed mobility. The resident's care plan required frequent repositioning, regular skin inspections during care, and prompt notification of new skin conditions. Despite these requirements, weekly skin observation records showed significant gaps, with no new skin impairments documented over several weeks, and a 35-day lapse between observations during which a new, unstageable pressure ulcer developed on the resident's coccyx. A hospice bath aide first noted an open sore on the resident's bottom, and hospice staff left a handwritten note for facility staff regarding the new wound. However, the note was not acted upon, as the responsible nurse was absent and did not ensure the information was communicated to oncoming staff. Progress notes and interviews revealed that a wound dressing order was placed but not implemented, and there was no prior written order for a dressing. The facility's investigation confirmed a breakdown in the skin/wound management process and a lack of nurse follow-up regarding treatment orders. Interviews with staff indicated that the hospice provider discovered the wound before facility staff did, and that required weekly skin observations and documentation were not completed as per protocol. The delay in identifying and treating the pressure ulcer resulted from missed observations, lack of communication among staff, and failure to follow up on treatment orders, leading to inadequate evaluation and delayed care for the resident's pressure ulcer.
Inaccurate RN Staffing Information Posted
Penalty
Summary
The facility failed to ensure that the Direct Care Staff Daily Report (DCSDR) postings accurately reflected Registered Nurse (RN) staffing for five out of seven days reviewed. Record review showed that the posted RN coverage was inaccurate on multiple specific dates. This was confirmed by the staffing coordinator, who acknowledged the discrepancies in the DCSDR postings for those days. No information was provided regarding the involvement of specific residents or their medical conditions at the time of the deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of Hillsboro | 1.3 mi | ★★★★★ | 20 | 1 |
| Forest Grove Post Acute | 5.9 mi | ★★★★★ | 0 | 0 |
| Marquis Forest Grove Post Acute Rehab | 6.4 mi | ★★★★★ | 5 | 0 |
| Maryville | 7 mi | ★★★★★ | 1 | 0 |
| Beaverton Post Acute Care Of Cascadia | 8.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.