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Complaint Investigation

Hillsboro Health And Rehabilitation

August 12, 2025 · Hillsboro, OR · 1778 Ne Cornell Road
Citations 3
CMS Rating 4/5
Beds 78
Provider ID 385217
Healthcare Facility
Hillsboro Health And Rehabilitation
Hillsboro, OR  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

HILLSBORO HEALTH AND REHABILITATION in HILLSBORO, OR — inspection on August 12, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies

authorities.

Agency for 2 of 2 sampled residents (#s 6 and 10) reviewed for abuse.

This placed residents at risk

6's 6/9/25 MDS revealed Resident 6 had a BIMS of 5, which indicated a severe cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 6 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.Resident 10's 1/29/25 MDS revealed Resident 10 had a BIMS of 8, which indicated a moderate cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 10 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.On 8/11/25 at 1:04 PM, Staff 20 (CMA) stated she saw Resident 6 sitting on Resident 10's bed on 6/9/25.

She stated Resident 10 was touching Resident 6's breasts and was offering Resident 6 money.

She stated staff separated Resident 6 and Resident 10.On 8/11/25 at 1:07 PM, Resident 10 stated she/he did not remember the incident.Resident 6 was not able to be interviewed as she/he was no longer in the facility.On 8/12/25 at 10:17 AM, Staff 21 (RN) stated she saw Resident 6 go into Resident 10's room and she observed them kissing on 6/9/25.

She stated staff re-directed Resident 6 away from Resident 10.On 8/12/24 at 11:58 AM, Staff 3 (LPN Resident Care Manager) stated Resident 6 and Resident 10 were observed kissing on 6/8/25 and 6/9/25. He was made aware on 6/9/25 and completed the sexual consent evaluations for each resident and determined neither Resident 6 nor Resident 10 could consent to intimate activity. On 8/12/25 @ 12:30 PM, Staff 1 (Administrator) stated he was unable to locate any evidence the event was reported to the State Agency and that it was his responsibility to report to the State Agency.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

385217 08/12/2025

Hillsboro Health & Rehabilitation Center 1778 NE Cornell Road Hillsboro, OR 97124

include:Resident 6 admitted 1/2025 with diagnoses including dementia.Resident 6's 6/9/25 MDS

Capacity Evaluation indicated Resident 6 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.Resident 10's 1/29/25 MDS revealed Resident 10 had a BIMS of 8, which indicated a moderate cognitive impairment.A 6/9/25 Sexual Capacity Evaluation indicated Resident 10 did not have sufficient memory and/or cognitive function to make the choice for sexual activity.On 8/11/25 at 1:04 PM, Staff 20 (CMA) stated she saw Resident 6 sitting on Resident 10's bed on 6/9/25.

She stated Resident 10 was touching Resident 6's breasts and was offering Resident 6 money.

She stated staff separated Resident 6 and Resident 10.On 8/11/25 at 1:07 PM, Resident 10 stated she/he did not remember the incident.Resident 6 was not able to be interviewed as she/he was no longer in the facility.On 8/12/25 at 10:17 AM, Staff 21 (RN) stated she saw Resident 6 go into Resident 10's room, and she observed them kissing on 6/9/25.

She stated staff re-directed Resident 6 away from Resident 10.On 8/12/24 at 11:58 AM, Staff 3 (LPN Resident Care Manager) stated Resident 6 and Resident 10 were observed kissing on 6/8/25 and 6/9/25. He was made aware on 6/9/25 and completed the sexual consent evaluations for each resident and determined neither Resident 6 nor Resident 10 could consent to intimate activity. On 8/12/25 at 12:30 PM, Staff 1 (Administrator) stated he was unable to locate any evidence that the incident was investigated, and it was the Administrator's responsibility to complete the investigation.

385217 08/12/2025

Hillsboro Health & Rehabilitation Center 1778 NE Cornell Road Hillsboro, OR 97124

prevent accidents.

supervision and assistance devices to prevent accidents for 1 of 1 sampled resident (#5) reviewed for

admitted in 7/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side.Resident 5's 7/18/25 care plan indicated Device: Seat belt-gait belt from home and Mobility Device: Electric wheelchair, assist resident with seat belt.A 7/20/25 progress note indicated Resident 5 was found on the floor, stated she/he slid out of her wheelchair and called emergency from her/his personal cell phone. Resident 5 had a laceration on her/his leg and was bleeding. Resident 5 was taken to the hospital for evaluation.On 8/8/25 at 12:28 PM, Staff 12 stated Resident 5 slipped out of her/his wheelchair and onto the floor. He further stated he could not get Resident 5's seat belt around her/him because it was too small. He was unsure if use of the seat belt was in the care plan and stated he did not inform anyone the seat belt was too small because it was known.On 8/8/25 at 3:17 PM, Resident 5 reported she/he fell on the floor and her/his leg was bleeding.

She/he yelled for help, but no one came. Resident 5 indicated she/he was scared and called 911 and was taken to the hospital. On 8/12/25 at 10:31 AM, Staff 22 (LPN) stated she saw Resident 5 during the morning medication pass.

She did not know if Resident 5 was wearing a seat belt when she/he fell and was not sure if she/he was care-planned for its use.On 8/12/25 at 1:19 PM, Staff 1 (Administrator) stated he expected all staff to follow the care plan to prevent accidents.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HILLSBORO, OR, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HILLSBORO HEALTH AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.