Hillsboro Health and Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF730Aug 21, 2026

  Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNAs (#s 4, 5, 6, 7 and 8) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of competent staff. Findings include: On 8/20/26 at 11:43 AM annual performance reviews for Staff 4 (CNA), Staff 5 (CNA), Staff 6 (CNA), Staff 7 (CNA), and Staff 8 (CNA) were requested from Staff 1 (Administrator). Staff 1 stated annual performance reviews were not completed for any facility CNAs.On 8/21/26 at 11:22 AM Staff 12 (Human Resources) stated no facility CNAs received annual performance reviews because they were part of a union. […]

• No harm, potential for more than minimal, patternF757Aug 21, 2026

  Based on interview and record review it was determined the facility failed to ensure medication was held when contraindicated for 3 of 6 sampled residents (#s 2, 3, 28) reviewed for hospitalization, unnecessary medications. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 2 admitted to the facility in 10/2025 with diagnoses including atrial fibrillation, heart failure, and high blood pressure. A physician order for carvedilol dated 10/4/25 stated to not administer carvedilol (a medication for heart failure and high blood pressure) for a systolic blood pressure (the top number of the blood pressure) less than 100 or a heart rate less than 60. […]

• No harm, potential for more than minimal, patternF761Aug 21, 2026

  Based on observation, interview and record review it was determined the facility failed to ensure all insulin vials and pens were stored and labeled properly for 2 of 4 medication/treatment carts reviewed for medication storage. This placed residents at risk for receiving incorrect or expired insulin. Findings include:The facility policy as outlined in the Nursing Care Center Pharmacy Policy and Procedure Manual: Medication Storage, Storage of Medication last revised 1/2023 revealed, note the date on the label for insulin vials and pen when first used.On [DATE] at 9:30 AM the medication cart for the back half of the 300 hall was observed to contain three multidose insulin pens that were not labeled with open dates. […]

• No harm, potential for more than minimal, patternF584Feb 9, 2024

  Based on observation and interview it was determined the facility failed to ensure a homelike environment for 1 of 1 facility reviewed for homelike environment. This placed residents at risk for adverse health conditions and an unclean environment. Findings include: Observations of the facility's general environment and residents' rooms from 2/5/24 through 2/9/24 identified the following issues: -Dirty floor vents inside the beauty shop, outside the beauty shop, outside of rooms [ROOM NUMBERS]. -Four dime sized holes on the wall next to the timeclock. -One brown water stained ceiling tile in the main dining area near the kitchen entrance, two brown water stained ceiling tiles outside room [ROOM NUMBER]. […]

• No harm, potential for more than minimal, patternF684Feb 9, 2024

  Based on observation, interview and record review it was determined the facility failed to ensure physician orders were followed for 4 of 8 sampled residents (#s 32, 34, 36 and 42) reviewed for choices, care plans and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 36 was admitted to the facility in 7/2023 with diagnoses including type 2 diabetes mellitus, GERD (acid reflux), hypertension (high blood pressure) and chronic congestive heart failure (heart condition which can result in rapid weight gain from fluid build-up). a. Resident 36's 1/17/24 Quarterly MDS indicated the resident was cognitively intact. On 2/5/24 at 9:24 AM Resident 36 stated she/he received her/his Rybelsus (diabetic medication) late everyday. […]