Hillsboro Health and Rehab LLC

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff interviews and record reviews, the facility failed to provide and serve foods as planned by the Registered Dietitian (RD). This affected four Residents ( #1, #2, #57, and #4) of the four residents reviewed. The facility total census was 76. 1) Record review of Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 included diabetes, chronic obstructive pulmonary disease, morbid obesity, and respiratory failure. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed Resident #1 had intact cognition and required set up assistance for meal and unable to ambulate. Review of the physician order for Resident #1 dated 03/31/26, revealed the resident was ordered a consistent carbohydrate large portion diet. [...]

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure infection control standards were implemented. This affected four residents (Resident #80, Resident #13, Resident #62, and Resident #51) out of five residents reviewed for infection control. The facility census was 76. Findings Include: 1) Record review for Resident #80 revealed this resident was admitted to the facility on [DATE]. Diagnoses included acute posthemorrhagic anemia, dementia, and cerebrovascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 had severe cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) score of 01. This resident was assessed to require to be dependent on staff for all activities of daily living (ADL). Record review for Resident #13 revealed this resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, staff interview, and review of facility documentation, the facility failed to maintain comfortable water temperatures. This affected one (#10) out of the five residents reviewed for environment but had the potential to affect all 22 residents on the 100-hallway. The facility census was 76.

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure medications were labeled properly. This affected two residents (Resident #39 and Resident #4) out of five residents reviewed. The facility also failed to ensure immunizations were stored properly. This had the potential to affect all residents. The facility census is 76.

Inspectors wroteBased 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. In addition, the homeless shelter did not have staff with medical knowledge or training and had experienced recent funding cuts which resulted in no programs available to assist the resident in obtaining housing. [...]

Inspectors wroteBased on closed record review and staff interviews, the facility failed to provide notice of discharge timely and appropriately. This affected one resident (#79) out of the four residents reviewed for discharge. The facility census was 74.

Inspectors wroteBased 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.

Inspectors wroteTHE 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on record review, personal funds review, and staff interview, and review of a facility policy, the facility failed to return and complete final accounting of resident funds in a timely manner after a resident death. This affected one (#281) of one residents reviewed for discharged resident funds. The census was 78.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that pre-admission screening and resident review (PASARR) assessments were completed and failed to follow up on PASARR level II determinations. This affected two (#24 and #32) of two resident reviewed for PASARR assessments. The census was 78.

Inspectors wroteBased on observation, staff and resident interview, medical record review, and review of a facility policy, the facility failed to ensure residents received hearing supports and devices in a timely manner. This affected one (#2) of one residents reviewed for hearing ancillary services. The census was 78.

Inspectors wroteBased on medical record review staff interview, and review of Food and Drug Administration (FDA) medication information, the facility failed to provide an appropriate diagnosis for the use of psychotropic medications. This affected one (#22) of five residents reviewed for unnecessary medications. The census was 78.

Inspectors wroteBased on observation, medical record review, staff and resident interviews, review of meal tickets, and review of a facility policy, the facility failed to ensure resident food preferences were honored. This affected two (#6 and #18) of two residents reviewed for food preferences. The census was 78.

Inspectors wroteBased on state/federal economic stimulus and Medicaid guidelines, resident financial record review, staff interview, and facility policy review, the facility failed to ensure the resident's financial accounts were maintained within the appropriate limits. This affected twelve residents (Residents #28, #35, #40, #43, #50, #59, #64, #68, #71, #74, #75 and #79) of thirty-eight resident financial records reviewed. The facility census was 86.

Inspectors wroteBased on medical record review and staff interview, the facility failed to update a resident's Pre-admission Screening and Resident Review (PASARR) when a significant change occurred or was discovered. This affected two (Resident #4 and #33) of two residents reviewed for PASARR. The facility census was 86.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to ensure pressure relieving devices to prevent new or worsening pressure ulcers were in place as ordered by the physician. This affected one (Resident #11) of five residents reviewed for pressure ulcers. This facility identified nine residents residing in the facility who had pressure ulcers. The facility census was 86.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure fall prevention measures were in place as ordered by the physician. This affected one (Resident #59) of one resident reviewed for falls. The facility identified 14 residents who had falls in the past 90 days. The facility census was 86.