Hillsboro Rehab & HCC

In the surveyor’s words

From the most serious findings on record at Hillsboro Rehab & HCC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 13, 2022

  Based on observation, interview, and record review, the Facility failed to implement Infection Control Measures in order to prevent the spread of COVID-19 as evidenced by: not isolating COVID-19 positive residents from negative residents; not isolating unvaccinated residents during COVID-19 outbreak; allowing COVID-19 positive residents to intermingle with other residents; not encouraging the use of masks/social distancing of residents; improper usage of Personal Protective Equipment (PPE); not posting signage for staff/residents/visitors education on appropriate isolation procedures; not implementing required environmental cleaning; and not implementing an effective infection control surveillance and tracking system during a COVID-19 outbreak. […]

• Immediate jeopardy, isolatedF689Sep 26, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopements for 1 of 8 residents (R49) reviewed for supervision to prevent elopements in a sample of 57. This failure resulted in an Immediate Jeopardy when on 8/17/24 at an unknown time, R49, who has a known history of elopement attempts and dementia, eloped from the facility without staff knowledge and was located 60 miles away from the facility. The Immediate Jeopardy began on 08/17/24 when R49 eloped from the facility without staff knowledge. R49 was last seen in the facility on 8/17/24 at 11:30 , and was found 60 miles away at his past home residence. Due to R49's physical and cognitive vulnerabilities, R49 had the likelihood of serious harm and injury when R49 eloped. […]

• Actual harm, isolatedF600Nov 4, 2025

  Based on observation, interview, and record review, the facility failed to prevent abuse from occurring and failed to document progressive interventions for 3 of 3 residents (R3, R7, R9) reviewed for abuse in the sample of 10. These failures resulted in R3 having R4's hands around her neck aggressively, R7 being hit in head by R4 and also being pushed down in chest by R4 while in bed, and R9 being slapped by R4. Using a reasonable person concept, R3, R7, and R9 would experience discomfort/pain and feelings of being scared, unsafe, shame, and humiliation. Findings include: R4's face sheet documents an admission date of 1/6/2025. Diagnoses include Vascular Dementia, Peripheral Vascular Disease, Chronic Atrial Fibrillation, and Cerebral Infarction. […]

• Actual harm, isolatedF689Nov 4, 2025

  Based on observation, interview, and record review, the facility failed to transfer 1 (R5) of 3 residents properly and failed to update a resident's care plan (R10) with progressive interventions to prevent future falls for 2 residents reviewed for accidents and falls in the sample of 3. These failures resulted in R5 having swelling and bruising to left ankle/lower leg and being diagnosed with an acute on chronic distal tibial fracture. Findings include: 1. R5's Care Plan documents at risk for falls r/t (related to deconditioning. Goals: the resident will be free from falls and injury through the review date. Intervention included utilize 2 assist for transfers dated 9/28/2025. R5's Quarterly Minimum Data Set (MDS), dated [DATE], documents R5 is alert. […]

• Actual harm, isolatedF686Oct 8, 2025

  Based on interview and record review, the facility failed to implement end of life/hospice skin care plan interventions for 1 of 3 (R2) residents reviewed for pressure ulcers in the sample of 5. This failure resulted in R2 developing multiple in-house acquired pressure ulcers between the dates of [DATE] and [DATE] when R2 expired at the facility. Findings include:R2's admission Record, print date of [DATE], documented R2 had diagnoses including dementia, COPD (chronic obstructive pulmonary disease), severe protein calorie malnutrition, thrombocytopenia, pressure ulcer of left heel, anxiety disorder, chronic atrial fibrillation, congestive heart failure, type 2 diabetes mellitus, osteoarthritis, and chronic kidney disease. […]