Hillsboro Health and Rehab LLC

In the surveyor’s words

From the most serious findings on record at Hillsboro Health and Rehab LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Oct 5, 2023

  Based on observation, review of open and closed medical records, staff interviews, review of a death certificate, review of water sample testing reports, review of weekly water temperature and chlorine level logs, review of water sample testing kit manufacturer's instructions, review of the facility's water management plan, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure the water system was accurately tested for chlorine levels and maintained in a safe manner which resulted in elevated levels of Legionella bacteria in the facility's water system and exposure to the residents. […]

• Immediate jeopardy, isolatedF627Dec 29, 2025

  Based on closed medical record review, observations, interviews with facility staff and a facility resident, interview with Medical Director #275, interviews with Resident Representatives, interviews with Homeless Shelter employees, interviews with insurance employees, and interview with Ombudsman #250, the facility failed to provide a safe discharge to an appropriate location for Resident #79. On 12/08/25 Resident #79, who had resided in the facility for more than 22 years, was discharged to a homeless shelter with no income and had limited skills, knowledge, and resources required to provide for himself. […]

• Actual harm, isolatedF689Oct 31, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observations, record reviews, and interviews, the facility failed to ensure residents were transferred in a manner to prevent major injury. This affected one resident (#24) out of the three residents reviewed for accidents. The facility census was 86. Actual harm occurred on 10/05/23 at approximately 1:00 P.M. when Resident #24 sustained a fracture of the right distal tibia during a staff assisted transfer from the resident's room to the shower room in a shower chair which did not have leg and foot support. […]

• No harm, potential for more than minimal, widespreadF812May 28, 2026

  Based on observation, staff interviews and record reviews, the facility failed to ensure food was stored, prepared and served in a safe and sanitary manner to prevent foodborne illness. This affected all 76 residents who received foods from the kitchen. The facility total census was 76.Findings include:Observations during the kitchen tour on 05/26/26 at 8:17 A.M., revealed there were two ceiling vents directly above the food preparation areas and stove which had a visible buildup of gray colored debris. There were three stacks of unopened boxes of food stored directly on the floor of the freezer. There was an open thickener container with no open date. There was no thermometer inside the milk cooler.Review of the dishwasher temperature and sanitation log on 05/26/26 at 8:30 A.M. […]

• No harm, potential for more than minimal, widespreadF727Aug 13, 2025

  Based on record review and staff interview the facility failed to utilize the services of a registered nurse (RN) for at least eight hours a day, seven days a week as required. This had the potential to affect all 74 residents residing at the facility. The facility census was 74.Findings Include:Review of facility staff records titled Daily Staffing dated 08/06/2025 through 08/13/2025, revealed that no RN was was staffed at the facility on 08/08/2025, 08/09/2025, 08/10/2025 and 08/13/2025.Interview with Director of Nursing and Administrator on 08/13/2025 confirmed that no RN was scheduled or worked on those days. This deficiency represents non-compliance investigated under Master Complaint Number 258139 Complaint Number 2574281.